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in  2010  with  funding  from 

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PEACTICAL  TREATISE 


ON  THE 


DISEASES  OE  THE  EAR, 


INCLUDING 


THE   ANATOMY  OF  THE   ORGAN. 


BY 

D.  B.  ST.  JOHN  ROOSA,  M.A.,  M.D., 

Professor  of  Diseases  of  the  Eye  and  Ear  in  the  University  of  the  City  of  New  York;  Surgeon 
to  the  Manhattan  Eye  and  Ear  Hospital ;  Consulting  Surgeon  to  the  Brooklyn  Eye 
atzd  Ear  Hospital ;  Consulting  Surgeon  to  the  New  York  Ear  Dispensary; 
Member  of  the  A  merican   Otological  Society ;   Fellow  of  the  New 
York  Academy  of  Medicine ;  Member  of  the  Medical  So- 
ciety of  the  County  of  New  York,  Etc.,  Etc. 


ILLUSTRATED    BY 
WOOD  ENGRAVINGS  AND  CHROMOLITHOGRAPHS. 


NEW  YORK: 
WILLIAM    WOOD    &    COMPANY, 

27    GREAT    JONES    STREET. 
1873. 


IZI 


Entered  according  to  Act  of  Congress,  in  the  year  1873,  by 

D.  B.  ST.  JOHN  BOOS  A, 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


Electrotyped  by  Smith  &  McDotjgal,  82  Beskman  Street. 


PREFACE. 


THIS  work  is  intended  to  be  a  guide  to  those  who  wish  to  treat 
the  diseases  of  the  ear.  The  portion  that  is  devoted  to  a 
description  of  these  diseases,  and  the  means  for  their  relief  and 
cure,  is  founded  upon  my  own  experience  in  the  observation  and 
treatment  of  more  than  thirty-eight  hundred  cases,  in  public  and 
private  practice.  I  have,  however,  taken  pains  to  give  the  experi- 
ence of  other  practitioners,  both  at  home  and  abroad.  I  have 
endeavored  not  only  to  give  a  comprehensive  digest  of  the  most 
recent  European  researches,  but  also  to  present  with  entire  impar- 
tiality, the  views  and  experiences  of  American  practitioners  and 
writers,  so  far  as  the  plan  of  a  practical  treatise  like  this  would 
allow.  To  give  a  complete  account  of  all  that  has  been  written  on 
Otology  has  not,  however,  been  my  aim. 

Considerable  space  has  been  given  to  illustrative  cases,  with  a 
view  of  showing  the  actual  symptoms  of  aural  diseases  and  the 
results  of  treatment.  I  have  also  added  historical  sketches  upon  all 
points  of  practice  that  are  new  or  still  under  discussion,  in  order 
that  the  successive  steps  by  which  our  present  position  has  been 
reached  might  be  distinctly  traced,  believing  that  thereby  the 
practitioner  will  often  be  saved  needless  labor  in  re-investigating 
and  re-experimenting.  The  nomenclature  contained  in  this  treatise 
is  that  which  I  have  found,  after  some  years  of  experience  in  lec- 
turing upon  diseases  of  the  ear,  most  readily  grasped  by  the  stu- 
dent, and  is,  I  believe,  founded  upon  the  real  nature  of  the  diseases. 

The  anatomical  portion  of  the  volume  has  been  compiled  from 
the  most  recent  authorities.  The  text-book  of  Professor  J.  Henle, 
of  Grdttingen,  a  work  which  has  not  been  translated  into  English, 
has  been  made  the  general  basis  of  the  descriptions  of  the  various 
parts  of  the  ear,  and  of  the  arrangement  of  the  subject. 

In  the  preface  to  a  translation  of  Von  Troltsch  on  the  Ear, 


IV  PREFACE. 

published  a  little  more  than  nine  years  since,  the  translator  had  so 
little  faith  in  a  general  professional  interest  in  the  diagnosis  and 
treatment  of  diseases  of  the  ear,  that  he  quoted  a  proverb  to  indi- 
cate that  an  ordinary  human  life  would  not  suffice  to  see  the  fruit 
of  the  tree  then  being  planted,  in  presenting  to  the  English-speak- 
ing profession  a  work  which  has  done  much  for  the  progress  of 
Otology.* 

In  view,  however,  of  the  active  and  permanent  interest  in  this 
subject,  which  has  shown  itself  in  the  formation  of  societies,  the 
establishment  of  journals,  improvements  in  methods  of  practice, 
and  a  general  appreciation  of  diseases  of  the  ear,  the  author  can 
but  felicitate  himself  that  even  in  a  short  life  he  has  seen  some 
fruit  of  a  tree,  which,  although  he  did  not  plant,  he  at  least  assisted 
in  cultivating. 

The  practice  of  Otology  in  this  country  was,  a  few  years  since, 
almost  exclusively  confined  to  charlatans ;  but  it  is  now  cultivated 
by  a  class  of  men  who  are  the  equals  of  any  in  the  profession.  Ten 
years  ago,  in  most  parts  of  the  country,  those  who  wished  advice 
upon  a  disease  of  the  ear  were  forced  to  seek  aid  outside  of  the  pro- 
fession. At  the  present  time,  there  can  be  found  those  in  the  large 
cities  who  are  constantly  and  successfully  treating  aural  diseases ; 
and  all  over  the  land  the  old  and  familiar  advice,  "  Not  to 
meddle  with  the  ear,"  is  growing  far  less  frequent.  The  day  will 
soon  arrive — if  indeed  it  be  not  already  upon  us — when  Otology  will 
take  equal  rank  with  Ophthalmology,  to  which  department  it  has 
so  long  been  a  mere  appendage,  and  when  some  knowledge  of  the 
diseases  and  treatment  of  the  ear,  will  be  required  of  every  prac- 
titioner. 

I  have  been  assisted  in  various  ways,  in  the  preparation  of  this 
work,  by  many  who  may  rest  assured  that  I  have  not  been  unmind- 
ful of  their  labors  because  their  names  are  not  here  mentioned ; 
but  to  Dr.  Charles  E.  Eider,  of  Rochester,  for  assistance  in  compile 
ing  the  anatomy  of  the  middle  ear,  and  to  Dr.  George  M.  Beard, 
for  critical  suggestions  in  the  literary  execution  of  the  work,  of  a 
very  valuable  character,  I  am  much  indebted,  and  to  both  of  these 
gentlemen,  I  desire  to  present  my  cordial  acknowledgments. 

It  is  believed  that  in  the  foot-notes,  the  various  authorities 
whom  I  have  consulted  have  been  given  proper  credit,  and  they 

*  "  Arbores  seret  diligens  agricola  quarum  adspiciet  baccam  ipse  nun- 
quam." 


PREFACE.  V 

are  given  in  full  at  the  close  of  the  sketch  of  the  progress  of  Oto- 
logy, and  at  the  end  of  each  anatomical  section,  in  order  that  an 
aural  bibliography  of  works  actually  consulted  by  the  author,  and 
accessible  in  this  country,  may  be  furnished  to  any  who  may  desire 
to  pursue  any  special  subjects  further  than  would  be  fitting  the 
limits  of  a  text-book. 

Most  of  the  engravings  were  made  by  Messrs.  J.  A.  Cough- 
Ian  &  Co.  Those  of  instruments  were  furnished  by  Messrs.  Shep- 
ard  &  Dudley,  Otto  &  Reynders,  and  George  Tiemanu  &  Co.,  of 
this  city. 

The  chromo-lithographs  were  drawn  by  Dr.  H.  P.  Quincy,  of 
Boston,  from  cases  loaned  me  by  Drs.  Clarence  J.  Blake  and  Henry 
L.  Shaw,  Surgeons  to  the  Massachusetts  Charitable  Eye  and  Ear 
Infirmary.  Without  the  assistance  of  these  gentlemen,  I  should 
have  found  it  very  difficult  to  procure  satisfactory  representa- 
tions of  the  morbid  membrana  tympani.  Dr.  John  L.  Vander- 
voort,  Librarian  of  the  New  York  Hospital,  has  extended  me  many 
courtesies  in  giving  me  free  access  to  the  valuable  library  of  that 
institution. 

New  York,  May  29,  1873. 


CONTENTS. 


PAET    I. 

INTRODUCTORY    SKETCH    AND    EXTERNAL    EAR. 


CHAPTER    I. 

INTRODUCTION. 

PAGE 

A  Sketch  of  the  Progress  of  Otology, 52 

CHAPTER    II. 

ANATOMY  OF  THE.  AURICLE  AND   EXTERNAL  AUDITORY  CANAL.     66 

CHAPTER    III. 

THE   EXAMINATION   OF  AURAL  PATIENTS. 

History — The  Watch  as  a  Test  of  Hearing — Eegister  of  Hearing  Power — 
The  Tuning-fork — Interference  Otoscope — Von  Conta's  Method — Aural 
Specula — Method  of  Holding  the  Speculum — Von  Trdltsch's  Otoscope — 
Binocular  Otoscope — Prismatic  Otoscope — Examination  of  the  Pharynx 
— Rhinoscopy — Eustachian  Catheter — Politzer's  and  Valsalva's  Methods 
— Bougies — Diagnostic  Tube,    .        .        . 100 

CHAPTER    IV. 

THE  DISEASES   OF  THE   AURICLE. 
Shape  of  the  Auricle — Its  Functions — Malformations — Othaematomata — 
Malignant  Growths — Eczema, 118 

CHAPTER    V. 

DIFFUSE   AND   CIRCUMSCRIBED   INFLAMMATION  OF  THE  EXTERNAL 

AUDITORY  CANAL. 
Comparative  Infrequency  of   these  Affections — Diffuse    Inflammation- 
Aural  Douche— Method  of  Syringing — Furuncles, 133 


Tjji  CONTENTS. 

CHAPTER    VI. 

PARASITIC   INFLAMMATION   OF   THE    EXTERNAL  AUDITORY   CANAL. 

PAGE 

Aspergillus — Penicilliuin — Graphium  Pencilloides  —  Trichothecium  Ro- 
seum— Cases— Syphilitic  Ulcers — Condylomata 145 

CHAPTER    VII. 

INSPISSATED   CERUMEN. 

Sudden  Impairment  of  Hearing  Power— Tinnitus  Aurium— Vertigo — 
Pain  in  the  Ear — Causes — Method  of  Removal— Cases — Composition  of 
Cerumen — Buchanan  on  the  Functions  of  Cerumen — Cerumen  around 
Foreign  Bodies — Mental  Hallucinations  relieved  by  removal  of  Har- 
dened Cerumen, 162 

CHAPTER    VIII. 

FOREIGN   BODIES   IN  THE   EAR. 
Insects — Living  Larva? — Other  Foreign  Bodies — Impression  that  the  Pres- 
ence of  a  Foreign  Body  is  in  the  Ear  is  very  Dangerous — Proper  Method 
of  Removal — Foreign  Bodies  in  the  Eustachian  Tube — Cases — Mental 
Illusions  as  to  the  Presence  of  Foreign  Bodies, 178 


PAET    II. 

THE    MIDDLE    EAR. 


CHAPTER    IX. 

ANATOMY   OF  THE   MIDDLE   EAR. 

The  Membrana  Tympani — Shrapnell's  Membrane— The  Rivinian  Fora- 
men— The  Light  Spot — Layers  of  Membrana  Tympani — Blood-vessels 
— Nerves — Lymphatics — The  Cavity  of  the  Tympanum — Scheme  for 
Studying  Walls  of  this  Cavity— Ossicula  Auditus  —  Blood-vessels — 
Nerves — The  Mastoid  Process — Mastoid  Cells — Blood-vessels — The  Eu- 
stachian Tube — Muscles  of  the  Tube — Nerves— Historical  Account  of — 
Authorities,        .        .        .        , 221 

CHAPTER    X. 

INJURIES  OF  THE  MEMBRANA  TYMPANI. 
No  Independent  Myringitis — Causes  of  Rupture  of  Drumhead — Explo- 
sion of  Artillery — Gruber's  Experiments  to  Determine  Resisting  Power 
of  Membrana  Tympani — Effects  of  Compressed  Air  upon  the  Membrane 
— The  Investigations  of  A.  H.  Smith,  Green,  and  Magnus — Violence  to 
Membrane  itself — Injury  of  Chorda  Tympani  Nerve — Functions  of  this 
Nerve — Medico-legal  Examinations — Evulsion  of  whole  Membrane — 
Fracture  of  the  Handle  of  Malleus, 236 


CONTENTS.  IX 

CHAPTER    XI. 

ACUTE  CATARRHAL  INFLAMMATION  OF  THE  MIDDLE  EAR. 

PAGE 

Nomenclature — Statistics  of  Acute  Catarrh — Frequency  of  the  Affection, 
although  it  is  not  often  Eeported — Symptoms — Diagnosis  in  Young 
Children — Bulging  of  the  Membrane — Causes — Treatment — Leeches — 
Paracentesis — Sub-acute  Catarrh — Cases — Otitis  Media  Hemorrhagica 
— Cases — Aural  Hemorrhage  in  the  Course  of  Bright's  Disease,      .         .  257 

CHAPTER    XII. 

CHRONIC   NON-SUPPURATIVE   INFLAMMATION  OF  THE  MIDDLE   EAR. 

Frequency  of  this  Disease — Nomenclature — Catarrh — Otitis  Media  Hyper- 
plastica — Proliferous  Inflammation — Subjective  Symptoms  of  Catarrh — 
Vertigo — Insanity  from  Aural  Disease — Tinnitus  Aurium — Subjective 
Symptoms  of  Proliferous  Inflammation — Objective  Symptoms — Impair- 
ment of  Hearing — Changes  in  the  Membrana  Tympani — Eustachian 
Tube — Naso-pharyngeal  Inflammation — Appearances  with  the  Rhino- 
scope — Pathology — Causes, .  287 

CHAPTER    XIII. 

CHRONIC    NONSUPPURATIVE   INFLAMMATION   OF   THE   MIDDLE  EAR 

— CONTINUED. 

Treatment  of  the  Catarrhal  and  Proliferous  Forms,  Constitutional  and 
Hygienic — Local  Blood-letting — Applications  to  the  Naso-pharyngeal 
Space  only  applicable  to  the  Catarrhal  Form — Injections  of  Naso-pha- 
ryngeal Space — Gargling — Cauterizations — Nasal  Douche — Cases  of  Oti- 
tis Media  from  Use  of  the  Douche — G  ruber's  Method  of  Cleansing  Nares 
— Nebulizers — Faucial  Catheter — Treatment  through  the  Eustachian 
Tube — Air  —  Vapors  —  Fluids  —  Bougies — Electricity — Cases  of  Death 
from  Use  of  Catheter — Length  of  Time  Cases  should  be  Treated,  .        .  318 

CHAPTER    XIV. 

THE  TREATMENT  OF   CHRONIC    NON-SUPPURATIVE    INFLAMMATION 

OF  THE   MIDDLE   EAR — CONCLUDED. 
i 
History  of  the  Operations  upon  the  Membrana  Tympani — Riolanus — Che- 

selden — Astley  Cooper — Karl  Himly — Supposed  Cases  of  Death  from 
Perforation  of  Membrana  Tympani — Schwartze's  Revival  of  the  Opera- 
tion— Politzer's  Eyelet — Excision  of  the  Malleus — Gruber5s  Myringo- 
dectomy — Weber's  Division  of  the  Tensor  Tympani — Gruber's  Knife — 
Lucae's  and  Politzer's  Incision  of  Posterior  Fold — Prout's  Operation — 
Hinton's  Operation — The  Effects  of  Condensed  Air  upon  the  Hearing 
Power — Exhaustion  of  the  Air  from  the  External  Auditory  Canal — Re- 
sults of  Treatment, .  349 


X  •  CONTENTS. 

CHAPTER    XV. 

•   ACUTE  SUPPURATION  OF  THE  MIDDLE  EAR. 

PAGE 

Result  of  Acute  Catarrh — Symptoms — Causes — Course — Treatment — Re- 
sults— Cases, 363 

CHAPTEE    XVI. 

CHRONIC    SUPPURATION    OF   THE   MIDDLE   EAR. 

Formerly  known  as  Otorrhoea — Often  confounded  with  Chronic  Suppura- 
tion— Relative  Frequency  of  Suppurative  Affections  of  the  External  and 
Middle  Ear — Symptoms — Perforations  of  Membrana  Tympani — Albu- 
minuria— Neglect  of  Chronic  Suppuration — Hearing  Power — Treatment 
— Nitrate  of  Silver — Electricity — The  Artificial  Membrana  Tympani — 

Prognosis — Cases, 386 

• 

CHAPTER    XVII. 

THE  CONSEQUENCES   OF  CHRONIC   SUPPURATION"  OF  THE    MIDDLE 

EAR. 

Importance  of  the  Subject — Life  Insurance  Companies  decline  to  Insure 
Patients  suffering  from  these  Consequences — Polypi — Malignant  Growths 
— Middle  Ear  Mirror — Exostoses — Cases  of  Exostoses — Mastoid  Disease 
— Illustrative  Cases — Caries  and  Necrosis  of  the  Temporal  Bone — Extrac- 
tion through  the  External  Meatus  of  the  Whole  Internal  Ear — Progno- 
sis of  Caries  and  Necrosis — Treatment — Cerebral  Abscess — Pyaemia — 
Paralysis — Table  showing  the  Course  and  Symptoms  of  Cases  of  Menin- 
gitis, Cerebral  Abscess,  and  Pyaemia  resulting  from  Aural  Disease,         .  458 


PAET    III. 

THE    INTERNAL    EAR, 


CHAPTER    XVIII. 

ANATOMY  OF  THE  INTERNAL  EAR. 
Labyrinth— Division  of  Internal  Ear — Vestibule— Semicircular  Canals — 
Cochlea — Auditory  Nerve — Periosteum  of  the  Labyrinth— Utricle  and 
Membranous  Semicircular  Canals — Saccule— Ductus  Cochlearis,  or  La- 
mina Spiralis  Membranacea — Terminal  Auditory  Apparatus — Auditory 
Rods — Membrana  Reticularis — Auditory  Cells— Blood-vessels — Authori- 
ties,   .        .........        ....        ...        .  .  484 


CONTENTS.  XI 

CHAPTER    XIX. 

DISEASES   OF  THE  INTERNAL  EAR. 

PAGE 

Definition  of  Nervous  Deafness — Most  unfrequent  of  all  Aural  Diseases — 
Symptoms — Deafness  to  certain  Tones — Double  Hearing — Meniere's 
Cases — Electricity  in  the  Diagnosis  of  Disease  of  the  Auditory  Nerve — 
Causes — Injuries — Hemorrhages  and  Effusions — Inflammation  of  the 
Membranous  Labyrinth — Quinine — Concussion — Eemote  Causes — Syph- 
ilis— Cerebrospinal  Meningitis — Fevers — The  Exanthemata — Mumps 
— Cerebral  Tumors — Aneurism — Pathology — Treatment — Electricity — 
Otalgia, 512 


PA'ET      IV. 

DEAF-MUTEISM    AND    HEARING    TRUMPETS. 


CHAPTER    XX. 

DEAF-MUTEISM. 

Acquired  and  Congenital  Cases — Causes — Appearances  of  Membrana  Tym- 
pani  and  Pharynx — Treatment — Number  of  Deaf  Mutes  in  the  United 
States — Hearing  Trumpets,       .........  521 

Description  of  Chromo-lithographs,       .         .        ,        .        .        .  .  525 

Index  of  Authors,  ............  525 

General  Index ,.  529 


LIST    OF    WOOD-CUTS. 


FIG.  PAGE 

1.  Normal  Auricle,   .         . 53 

2.  Profile  View  of  the  Skull,  with  the  Skeleton  or  Cartilage  of  the  Auri- 

cle, as  well  as  that  of  the  External  Auditory  Canal,         .        .         .54 

3.  Muscles  of  the  External  Ear, 57 

4.  View  of  the  Cartilage  and  Muscles  on  the  Posterior  Surface  of  the 

Auricle 58 

5.  Horizontal  Section  of  the  Head,  through  the  External  Auditory  Canal,     60 

6.  Section  through  the  External  Meatus  and  the  Ear  at  the  Point  of 

Junction  of  the  Cartilage  of  the  Auricle  with  that  of  the  Auditory 
Canal, 61 

7.  Vertical  Section  of  the  Osseous  Meatus,  Right  Side,  close  to  the  Mem- 

brana  Tympani, 65 

8.  Blake's  Tuning-fork, 76 

9.  Angular  Forceps 80 

10.  Gruber's  Speculum,        .        .        . 80 

11.  Method  of  Holding  the  Speculum  in  Position,      .        ...        .         .82 

12.  Von  Troltsch's  Otoscope,  actual  size, 83 

13.  Method  of  Examining  the  Auditory  Canal  and  Membrana  Tympani,  84 

14.  Forehead-band 86 

15.  Blake's  Operating  Otoscope, 87 

16.  Hinge  Speculum,   .        .         .        .        , 88 

17.  Turck's  Speculum, 89 

18.  Tobold's  Lamp, 90 

19.  Anterior  Nares  Speculum,                               , 91 

20.  Eustachian  Catheters,  actual  size, 94 

21.  Introduction  of  Eustachian  Catheter, 95 

22.  Introduction  of  Eustachian  Catheter  (second  position)  .        .        .96 

23.  Air-bag 96 

24.  Diagnostic  Tube, 97 

25.  Method  of  using  Politzer's  Apparatus.     (With  Inhaler  Attachment.)  99 

26.  Othematoma.     From  a  Photograph  taken  from  a  Plaster  Cast  when 

the  Tumefaction  was  greatest, 109 

27.  The  same  Ear,  after  Rupture  and  Contraction  had  taken  place, .         .   109 

28.  Otkseinatonia;  showing  Amount  of  Contraction  after  Rupture  of  Cyst,  110 

29.  "  shows  Separation  of  Perichondrium  from  the  Cartilage,  110 

30.  An  Auricle  Deformed  by  Inflammation, 113 

31.  E.  H.  Clarke's  Aural  Douche, 124 

32.  Hard  Rubber  Syringe 127 

33.  Method  of  Syringing  the  Ear, 128 

34.  Aspergillus  Nigricans, 137 


LIST   OF  WOOD-CUTS.  Xlll 

FIG.  PAGE 

35.  Aspergillus  Flavescens,  .        ■ 138 

36.  Specimen  of  the  Spores,  and  fully  developed  Growth  of  the  Asper- 

gillus Flavescens,       .  139 

37.  Penicillinm, 140 

38.  The  Right  Temporal  Bone,  without  the  Petrous  Portion,  in  connec- 

tion with  the  Ossicula  Auditus  of  a  newly-born  Child,  seen  from 
within,        ....         ........  183 

39.  Left  Temporal  Bone  of  the  same  Subject  as  preceding  Figure,   .        .182 

40.  The  Right  Temporal  Bone  of  a  newly-born  Child,  with  a  Dried  Mem- 

brana Tympani,  . 183 

41.  42.  View  of  Membrana  Tympani,  showing  Handle  of  Malleus  and 

Triangular  Spot  of  Light, 187 

43.  Layers  of  Membrana  Tympani, 189 

44.  The  Membrana  Tympani,  in  connection  with  the  Ossicula  Auditus  of 

the  Right  Temporal  Bone, 194 

45.  The  Right  Temporal  Bone,  with  the  Membrana  Tympani  and  Ossi- 

cula Auditus  of  an  Adult, 197 

46.  Ossicula  Auditus, 200 

47.  The  Ossicula  Auditus  of  the  Left  Cavity  of  the  Tympanum,  seen  from 

within, 201 

48.  Section  of  the  Head,  showing  the  Divisions  of  the  Ear  and  the  Naso- 

pharyngeal Cavity, 208 

49.  Transverse  Section  of  the  Upper  Part  of  the  Eustachian  Tube,  .         .  209 

50.  Transverse  Section  through  the  Lower  End  of  the  Eustachian  Tube,  210 

51.  Transverse  Section  through  the  Lower  End  of  the  Eustachian  Tube,  210 

52.  Lateral  Wall  of  the  Nasal  Cavities,  showing  the  Pharyngeal  Orifice 

of  the  Eustachian  Tube, 211 

53.  Transverse  Section  of  Eustachian  Tube  and  surrounding  Parts,  .  212 

54.  Section  of  the  Upper  Third  of  the  Eustachian  Tube,   .        .      ■  .         .  215 

55.  Section  of  the  Middle  Third  of  the  Eustachian  Tube, .        .        .        .216 

56.  Fracture  of  Handle  of  Malleus, 236 

57.  The  same,  showing  the  Fracture  reduced,    ......  236 

58.  Tuning-fork, .269 

59.  Siegle's  Speculum, 276 

60.  Pharyngitis  granulosa, 277 

61.  Noyes'  Eustachian  Catheter, .        .  280 

62.  Posterior  Nares  Syringe, ■  .        .  290 

63.  Nebulizer  for  Pharynx, 298 

64.  Pomeroy's  Faucial  Catheter, .  299 

65.  Apparatus  for  Steaming  the  Middle  Ear, 303 

66.  Hackley's  Eustachian  Nebulizer, 307 

67.  Apparatus  for  Inj  ecting  Vapors  into  the  Nasal  Passages,    .         .        .  309 

68.  Air-bag,  with  Inhaler  Attachment, 310 

69.  Weber's  Knife  for  Dividing  the  Tensor  Tympani  Muscle,  .         .        .  334 

70.  Gruber's  Knife  for  Dividing  the  Tensor  Tympani,        ....  337 

71.  Prout's  Knife  for  Incising  Adhesions, 340 

72.  Vessel  used  in  Syringing  the  Ear, 373 

73.  Toynbee's  Artificial  Membrana  Tympani, 376 


XIV  LIST   OF  WOOD-CUTS. 

FIG.  PAGE 

74.  Method  of  Inserting  Artificial  Membrana  Tympani,    ....  380 

75.  Section  of  Aural  Polypus, 390 

76.  Section  of  Aural  Polypus, 391 

77.  Section  of  Aural  Polypus, 392 

78.  Blake's  Modification  of  Wilde's  Snare,  with  Paracentesis  Needle,       .  395 

79.  Scissors  for  the  Kemoval  of  Aural  Polypi,    . 395 

80.  Hinton's  Forceps, 396 

81.  Angular  Glass  Rod  for  Applying  Acids  to  the  Cavity  of  the  Tym- 

panum,         397 

82.  Blake's  Middle  Ear  Mirror,   .        . 399 

83.  84.  Two  Views  of  Temporal  Bone,  Exfoliated  in  the  Course  of  Chronic 

Suppuration, 436 

85.  Left  Temporal  Bone,      .  439 

86.  Inner  Surface  of  the  same  Specimen, 439 

87.  Left  Temporal  Bone  sawed  through  External  Meatus,  Middle  Ear, 

and  Cochlea, 440 

88.  Right  Temporal  Bone,  showing  the  Cranial  Surface  of  the  Bone,        .  441 

89.  Horizontal  Section  through  the  Lower  Half  of  the  Left  Ear,        .        .  462 

90.  The  Left  Vestibule,  with  the  Semicircular  Canals,  from  an  Adult,      .  463 

91.  The  Vestibule, 463 

92.  Osseous  Cochlea  and  Semicircular  Canals,  with  Stapes  Bone.     Left 

Ear  of  an  Adult, 465 

93.  Right  Osseous  Vestibule,  Semicircular  Canals,  Cochlea,  and  Ossicular 

Auditus  of  Newly -born, 465 

94.  The  Right  Osseous  Labyrinth  of  a  Newly-born  Subject,  opened  on 

its  Posterior  Surface, 465 

95.  Section  through  the  Apex  of  the  Right  Osseous  Cochlea,  parallel 

with  the  Base,    ........       I,        ,        .  466 

96.  Section  of  the  Temporal  Bone,  Vertical  to  its  Long  Axis.     Posterior 

Surface  of  the  Section, 467 

97.  Osseous  Cochlea  (Right)  of  the  Newly-born,  opened  from  the  Outer 

Surface,      . 468 

98.  Right  Osseous  Cochlea  opened  anteriorly, 469 

99.  Apex  of  the  Left  Osseous  Cochlea,  opened  to  show  the  End  of  the 

Lamina  Spiralis, 470 

100.  Expansion  of  the  Right  Cochlear  Nerve,  seen  from  the  Base  of  the 

Cochlea, 471 

101.  Periosteum  of  the  Labyrinth, 473 

102.  Periosteum  of  the  Outer  Wall  of  the  Cochlea, 473 

103.  Utricle  and  Membranous  Semicircidar  Canals  of  the  Left  Side,  .        .  473 

104.  Wall  of  Membranous  Semicircular  Canals, 474 

105.  A  Piece  of  the  Wall  of  the  Utricle,  with  the  Otoliths,         .        .        .475 

106.  Transverse  Section  cf  a  Cochlea  Spiral, 477 

107.  From  the  Terminal  Auditory  Apparatus  of  a  Cat,        ....  480 

108.  Profile  View  of  Outer  and  Inner  Rods, 480 

109.  Diagrammatic  Representation  of  the  Terminal  Auditory  Apparatus,  .  482 

110.  Hearing  Trumpets, 520 


PART  I. 
INTRODUCTORY  SKETCH  OF  THE  PROGRESS  OF  OTOLOGY. 

THE    EXTERNAL   EAR. 


INTRODUCTION. 


CHAPTER    I. 

A  SKETCH  OF  THE  PROGRESS  OF  OTOLOGY. 

Theee  is  perhaps  no  department  of  the  art  and  science  of 
medicine  in  which  there  has  been  so  much  literature,  with  so 
little  exact,  or  as  we  say,  scientific  knowledge,  as  that  which 
was  formerly  known  as  aural  medicine  and  surgery,  but  which 

is  better  designated  by  the  term  Otology. 
460-370  B.Ci]        Hundreds  and  perhaps  thousands  of  volumes 

have  been  written  on  the  anatomy,  physiology, 
and  diseases  of  the  ear,  from  the  time  of  Hippocrates  until 
our  own  day,  and  yet  until  the  age  of  Valsalva,  the  seventeenth 
century,  the  treatment  of  the  affections  of  the  organ  of  hear- 
ing was  purely  empirical,  while  the  knowledge  of  its  anatomy 
and  physiology  was  often  incorrect  and  fragmentary.  Even 
after  the  investigations  of  the  famous  Italian,  investigations 
which  consumed  sixteen  years  of  his  life,  and  the  subsequent 
anatomical  discoveries  of  the  eighteenth  century,  it  was  re- 
served for  our  own  day  and  generation  to  place  the  science  of 
otology,  or  the  knowledge  of  the  anatomy,  physiology,  and 
diseases  of  the  ear,  on  a  level  with  that  of  other  fields  of  labor 
in  medicine. 

A  singular  apathy  in  regard  to  the  maladies  of  one  of  the 
most  important  organs  of  the  body,  an  inexplicable  ignorance 
as  to  their  results,  a  most  irrational  and  empirical  manner 
of  treatment,  have  been  our  heritage  from  the  fathers.  Prob- 
ably to-day,  in  the  closing  years  of  the  nineteenth  century, 
there  are  more  practitioners  of  medicine  who  view  aural  med- 
icine and  surgery  from  the  stand-point  of  the  errorists  of  the 


18  A   SKETCH   OF  THE 

dark  ages,  than  there  are  in  any  other  field.  It  is  to  be  feared 
that  even  now  many  wise  and  skillful  men  do  not  know,  that 
to  drop  stimulating  or  even  anodyne  applications  upon  a 
membrane  which  they  have  never  examined,  to  probe  an  ear 
for  wax  that  they  cannot  see,  are  purely  empirical  practices 
which  every  conscientious  physician  should  hold  in  ab- 
horrence. 

The  great  reformer  of  this  science,  Wilde*  wrote,  as 
late  as  1853,  that  "  the  affections  of  the  ear,  whether  func- 
tional or  organic,  are  spoken  of,  lectured  on,  written  of,  and 
described  (even  in  great  part  to  the  present  day),  not  accord- 
ing to  the  laws  of  pathology  which  regulate  other  diseases, 
but  by  a  single  symptom,  that  of  deafness.'''' 

It  is  with  no  desire  to  recount  the  details  of  the  long  and 
painful  story  of  the  gropings  in  the  dark,  which  have  charac- 
terized the  teachings  on  otology  from  the  days  of  the  philoso- 
pher of  Cos,  until  the  seventeenth  century,  that  the  author 
attempts  an  historical  sketch  of  our  progress  up  to  our  present 
position.  He  has  neither  the  time  nor  the  facilities  for  such 
a  task ;  but  he  has  simply  aimed  to  sketch  the  outline  history 
of  otology,  from  the  sources  to  which  he  has  been  able  to  gain 
access,  in  such  a  manner  as  to  show  the  obstacles  which,  until 
twenty  years  ago,  have  prevented  the  satisfactory  progress  of 
the  science. 

The  authorities  which  I  have  consulted  in  this  introduction 
will  be  found  at  the  close  of  the  chapter  ;  bnt  I  must  first  of 
all  make  especial  acknowledgment  of  my  indebtedness  for  the 
greater  part  of  my  material  to  that  valuable  compendium, 
LincMs  Handbucli  der  Ohrenheilkunde.  I  have,  however, 
consulted  the  original  authorities  as  far  as  the  best  medical 
library  of  New  York,  that  of  the  New  York  Hospital,  and  my 
own,  would  permit.  Where  no  other  authority  is  given  in  a 
foot-note,  Lincke  is  the  one  from  which  I  quote,  and  often  by 
an  exact  translation. 

The  discoveries  and  teachings  in  the  anatomy  of  the  ear 
will  be  first  reviewed,  after  which  the  progress  in  the  examin- 
ation and  treatment  of  its  diseases  will  be  noted. 

*  Aural  Surgery,  English  edition,  p.  7. 


PBOGEESS  OF  OTOLOGY.  19 

PROGRESS  IN  THE  ANATOMY  OF  THE  EAR. 

Hippocrates  probably  knew  very  little  of  the  anatomy  of 
the  ear,  although  it  is  supposed  on  doubtful  grounds 
570  B.C.]  that  Alcmceon,  a  disciple  of  Pythagoras,  was  aware 
of  the  passage  that  led  from  the  cavity  of  the  tym- 
panum to  the  throat,  inasmuch  as  Aristotle  quotes  him  as 

saying  that  goats  breathed  through  their  ears. 
384-322  B.C.]        The  knowledge  of  Aristotle  as  to  the  ana- 
tomy of  the  ear  did  not  go  beyond  the  mem- 
brana  tympani. 
A.D.  98-1 17]        Rvfus  of  Epliesus,  who  was  the  first  medical  lex- 
icographer, and  who  lived  in  the  age  of  Pliny,* 
used  the  names  helix,  lobe,  tragus,  and  anti-tragus,  which  are 
still  employed  to  describe  the  different  parts  of  the  auricle. 

Marinus,  the  preceptor  of  Galen,  and  whom  Galen  named 
the  restorer  of  anatomy,  called  the  acoustic  and  facial  nerve 

one,  under  the  name  of  the  fifth  pair. 
A.D.  130]  Galen  does  not  seem  to  have  made  any  great 
advance  in  anatomical  studies,  and  they  were  greatly 
neglected  down  to  the  fifteenth  century.  The  darkness  of  the 
blind  leading  the  blind  is  scarcely  broken  for  thirteen  hundred 
years.  What  Galen  wrote  was  authority,  and  naught  else. 
One  valiant  skeptic  in  medicine  would  have  effected  more 
good  during  these  centuries,  than  all  the  ponderous  tomes  that 
were  written  by  philosophers  who  reasoned  upon  premises 
that  had  never  been  thoroughly  established.  So  late  as  1559 
one  Doctor  Geynes  was  called  before  the  College  of  Physicians 
in  London,  for  impugning  the  fallibility  of  Galen.  On  his  ac- 
knowledgment of  his  error,  however,  he  was  again  received 
into  the  college.f 

The  strong  arm  of  the  church,  in  the  dark  ages,  prevented 
anatomical  investigations  on  the  human  cadaver,  and  for  hun- 
dreds of  years  anatomical  knowledge  remained  at  a  stand -still. 
Galen,  however,  corrected  the  error  of  his  preceptor  in 
thinking  that  the  facial  and  acoustic  nerves  were  one,  and 
showed  that  the  latter  entered  the  meatus  auditorius  internus, 

*  History  of  Medicine.     Dunglison,  p.  166. 

f  Chambers'  Encyclopedia.    American  edition.    Article,  Galenus  or  Galen. 


20  A  SKETCH  OF  THE 

a  passage  which  his  predecessors  had  regarded  as  impermea- 
ble.    He  gives  no  account  of  the  anatomy  of  the  internal  ear, 
although  he  compares  it  to  a  labyrinth,  a  name  which  Fallo- 
pius,  fourteen  hundred  years  later,  fastened  on  it  forever. 
There  is  no  record  of  the  ossicula  auditus  until  the  fifteenth 

century.  Two  Italian  anatomists,  Achilini  and  Beren- 
1480]  gario,  were  the  first  to  describe  these  bones,  although 

they  were  not  the  discoverers  of  them. 

Berengario  also  first  described   the  membrana   tympani 

"  with  exactness."     The  exactness  of  his  knowledge  may  be 

shown  by  the  fact,  that  he  was  doubtful  whether  the  origin  of 

the  membrane  was  from  the  acoustic  nerve,  or  the  meninges  of 

the  brain. 
1542]        Andreas  Vesalius,  who  is  said  to  have  been  the  most 

accurate  anatomist  of  his  day,*  described  the  long  pro- 
cess of  the  malleus,  the  Eustachian  tube,  the  vestibule,  and 

the  semicircular  canals. 
16C4]        The  honor  of  the  discovery  of  the   stapes  bone  is 

claimed  by  no  less  than  three  anatomists,  viz.,  Ingrassia, 
Oolumbo,  and  the  renowned  Bartohmmeo  Eustachius.  The  former 
wrote  commentaries  upon  Galen's  works,  that  were  published 
long  after  his  death.    He  claims  to  have  shown  it  to  his  scholars 

in  1546,  at  Naples. 
1523-1562]  Gabriel  Fallopius,  of  Modena,  died  in  the  bloom 
of  youth,  at  the  age  of  39,t  but  he  lived  long  enough 
to  accomplish  much  for  anatomical  science.  He  showed,  among 
other  valuable  points  in  the  anatomy  of  the  ear,  that  the  mas- 
toid cells  communicated  with  the  cavity  of  the  tympanum. 
He  described  the  fenestras  rotunda  and  ovalis,  and  gave  his 
name  to  the  canal  in  which  runs  the  facial  nerve  in  its  passage 
through  the  cavity  of  the  tympanum,  acqiimductus  Fallopii. 

The  great  Guvier  regarded  Vesalius,  Eustachius,  and  Fallo- 
pius as  the  three  anatomists  of  the  sixteenth  century  to  whom 
belongs  the  honor  of  having  restored  the  science  of  ana- 
tomy. 
1500-1574]        Bartohmmeo  Eustachius    described   the   tensor 
tympani   as  well  as   the  stapedius   muscle.      He 

*  Dunglison.    History  of  Medicine,  p.  233. 
f  Chambers'  Encyclopedia.    Article,  Fallopius. 


PBOGEESS   OF  OTOLOGY.  21 

also  gave  a  more  exact  account  of  the  tube  leading  from 
the  pharynx  to  the  middle  ear,  which  is  called  the  Eustachian 
tube,  although  it  was  discovered  by  Vesalius.  Eustachius  also 
gave  a  superficial  description  of  the  cochlea. 

It  is  said  that  if  poverty  had  not  prevented  Eustachius 
from  publishing  his  anatomical  plates,  anatomy  would  have 
attained  the  perfection  of  the  eighteenth  century  some  two 

hundred  years  earlier.* 
1587]        The  first  monograph  on  the  anatomy  of  the  ear  was 
from  the  pen  of   Volcher  Koiter,  a  student  of  Eallopius. 
It  contained  no  original  observations,  however. 
1543-1573]         Constant  Varolius,f  so  well  known  from  his  de- 
scriptions of  the  brain,  made  the  singular  mistake 
of  supposing  that  the  muscles  of  the  cavity  of  the  tympanum 
were  nerves  which  were  torn  by  the  sawing  through  of  the 
bone.     Subsequently  he  admitted  this  error  ;  but  he  went  so 
far  to  the  other  side  as  to  say  that  the  tensor  and  laxator  tym- 

pani  muscles  could  be  moved  at  will. 
1537-1619]  Lincke^:  does  not  think  that  the  famous  Fabri- 
cius  of  Acquapendente,  contributed  very  much  to 
our  knowledge  of  the  anatomy  of  the  ear,  while  he  led  many 
away  into  error  as  to  some  points.  For  example,  he  thought 
that  the  chorda  tympani  nerve  was  a  peculiar  body,  and  not 
a  nerve.  At  any  rate,  Eabricius  did  good  service  by  his 
labors  as  a  comparative  anatomist,  and  it  should  be  remem- 
bered that  he  was  the  instructor  of  the  discoverer  of  the  circu- 
lation of  the  blood. 
1593-1G09]  Julius  Casserius,  who  was  a  professor  in  Venice 
in  1609,  a  pupil  and  subsequently  a  rival  of  Fabri- 
cius,  described  the  fissures  that  make  the  cartilaginous  por- 
tion of  the  canal  so  flexible.  He  and  Eabricius  described  the 
laxator  tympani  minor  in  the  same  year,  and  both  claim  to 
have  discovered  it  first.  Casserius  also  gave  a  better  descrip- 
tion than  had  hitherto  been  done  of  the  membrana  tympani, 
the  ossicula  auditus,  and  the  labyrinth.    He  was  the  first  to 

*  Chambers'  Encyclopedia.   Article,  Eustachius. 
\  Biographie  Medicale.     Paris,  Pankoucki. 
X  Handbuch,  Bd.  I.,  s.  14. 


22  A   SKETCH   OF  THE 

describe  the  three  and  a  half  turns  of  the  cochlea  and  the 

membranous  zone, 
1665]        The  ceruminous  glands,  whose  function  and  physio- 
logical action  were  first  described  by  Nicolaus  Stenon. 
Lincke  speaks  of  him  as  Stenson  ;  but  this  must  be  a  mistake 
in  transcribing  the  name  of  the  great  Danish  anatomist. 

Passing  on  to  the  eighteenth  century  we  find  Antonine 
Marie  Valsalva  rising  up  a  head-and-shoulders  above  the  anat- 
omists of  his  age,  and  far  exceeding  his  predecessors  in  the 
amount  and  exactness  of  his  knowledge. 

He  devoted  more  than  sixteen  years  of  his  life  to  the  study 
of  the  anatomy  of  the  ear,  and  for  the  purpose  of  its  study 
dissected  more  than  a  thousand  heads.  His  master- work  was 
a  treatise  on  the  ear.*  This  work  passed  through  five  edi- 
tions in  a  short  time.  He  described  the  attachment  of  the 
tensor  tympani  to  the  Eustachian  tube.  He  made  the  mis- 
take, however,  of  supposing  that  the  ossicula  auditus  had  no 
periosteum,  and  that  the  cavity  of  the  tympanum  was  con- 
nected by  many  openings  to  the  cavity  of  the  cranium.  He 
discovered  the  muscle  that  dilates  the  Eustachian  tube  and 
moves  the  uvula.  He  also  showed  that  the  fenestra  ovalis 
was  covered  by  membrane.  His  anatomical  plates  show  a 
good  knowledge  of  the  cochlea  and  semicircular  canals. 

Morgagni,  himself  an  original  investigator,  a  student  and 
friend  of  Valsalva,  edited  his  master's  work  and  made  some 
additions. 

Of  Valsalva's  contributions  to  the  treatment  of  the  ear, 
which  were  quite  as  important  as  his  anatomical  investiga- 
tions, we  shall  have  occasion  to  speak  in  the  second  part  of 

this  sketch. 
1714]  Valsalva  had  a  rival,  whose  name  the  lapse  of  time 
has  well  nigh  effaced,  Raymond  Vieussens,  who  also 
wrote  a  work  on  the  ear.  He  gave  new  names  to  various 
parts  of  the  organ  ;  but  his  descriptions  are  said  by  Lincke 
to  be  so  mysterious  that  his  contemporaries  could  not  under- 
stand them. 
1717]        Rivinus,  professor  in  Leipsic,  observed  an  opening 

*  Tractatus  de  Aure  Humana.     Lugdumirn  Batavorum,  1742. 


PEOGEESS   OP  OTOLOGY.  23 

in  the  membrana  tympani,  which  he  believed  to  be  a  constant 
anatomical  condition.  This  supposed  discovery  excited  the 
warmest  discussion  among  such  anatomists  as  Walther,  Buysck, 
Morgagni,  Cassebohn,  and  Valsalva.  Hyrtl,  the  present  dis- 
tinguished anatomical  teacher  of  Vienna,  showed  that  it  was 
a  rent  in  a  macerated  membrane  ;  but  his  predecessor,  Berres, 
believed  in  its  existence  and  described  it  minutely.* 

Quite  recently  Professor  Bochdalek,  of  Prague,  has  revived 
the  question,f  and  has  described  the  foramen  of  Bivinus  as  a 
constant  opening  in  the  membrana  tympani ;  this  author  says 
that  there  are  sometimes  two.  It  is,  however,  according  to 
Bochdalek,  so  small  as  not  to  be  seen  without  the  aid  of  a 
magnifying  glass. 

In  a  discussion  in  one  of  the  medical  societies  of  Vienna,:): 
Professors   von  Patruban,    Gruber,    and    Politzer,   unite    in 
affirming  its  existence,   thus  confirming    Bochdalek's   state- 
ment. 
1718]        The  famous  Ruysch  (Frederick),  professor  in  Amster- 
dam, contributed  to  our  knowledge  of  the  distribution  of 
the  vessels  of  the  cavity  of  the  tympanum,  and  corrected  Val- 
salva's statement  that  the  ossicula  were  not  covered  by  peri- 
osteum. 
1730]         Cassebohm  (Joan.  Frid.),  published  a  monograph  upon 
the  ear,  in  six  parts,  which  Lincke  calls  "  a  monument 
to  the  German  industry  and  spirit  of  inquiry  of  the  time." 
"  Ein  Denkmal  deutschen  Fleisses  und  deutschen  Beobach- 
tungsgeistes." 

He  disproved  Valsalva's  idea  of  the  close  connection 
between  the  cavity  of  the  tympanum  and  the  cerebrum  ;  he 
described  the  cochlea,  and  the  development  of  the  auditory 

apparatus  in  the  foetus. 

1747-1753]        Brendel  and  Zinn,  two  Gottingen  anatomists,  the 

latter  of  whom  is  well  known  as  the  describer  of  the 

suspensory  ligament  of  the  lens,  known  as  the  zonula  of  Zinn, 

made  further  investigations  as  to  the  structure  of  the 

cochlea. 

1761]        Dominic  Cotugno,  or  Cotunni,  the  discoverer  of  the  fluid 

*  Prager  Viertel.  Yahrschrift,  1866,  I. 

■J-  Troltsch  on  the  Ear,  2d  American  edition,  p.  26. 

\  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  I. 


2-4  A  SKETCH  OF  THE 

of  the  labyrinth,  won  such  a  reputation  by  his  work  upon 
the  internal  ear,  that  he  was  called  to  the  anatomical  chair  at 
Naples.  He  was  the  first  clearly  to  show  that  the  labyrinth 
was  filled  with  fluid,  and  that  this  was  one  of  the  neces- 
sities for  the  perception  of  the  undulations   that  we    call 

sound. 
1747-1832]  Antonio  Scarpa  issued  a  work  on  the  structure 
of  the  ear,  which  brought  the  knowledge  of  its  inner 
arrangement  to  such  a  height  that  it  seemed  to  his  contem- 
poraries that  there  was  little  more  to  be  done.  The  investi- 
gations of  our  own  day  have  shown  how  premature  was  this 
expression.  Scarpa  wrote  upon  the  fenestra  rotunda,  which 
connects  the  tympanic  cavity  with  the  lamina  spiralis  of  the 
cochlea.  He  described  the  osseous  labyrinth  with  exactness, 
the  membranous  labyrinth,  and  the  expansion  of  the  acoustic 
nerve. 

Scarpa  was  secretary  to  the  octogenarian  Morgagni,  when 
the  latter  had  lost  his  sight,  and  he  wrote  letters  of  advice 

in  Latin  at  the  dictation  of  his  blind  preceptor. 
1797]        Alexander  Monro,*  "  Professor  of  Anatomy,  Medicine 

and  Surgery,"  in  the  University  of  Edinburgh,  was  the 
author  of  a  monograph  on  the  organ  of  hearing  in  man  and 
other  animals.  It  is  a  fine  specimen  of  typography.  In  his 
preface  he  states  that  Dr.  Camper  called  in  question  his 
description  of  the  semicircular  canal  in  whales,  and  that 
Scarpa  said  that  some  of  his  teachings  in  regard  to  the 
human  ear  were  erroneous.  Professor  Monro  claims  to  have 
been  the  first  anatomist  to  trace  the  auditory  nerve  within 
the  cochlea,  vestibule,  and  semicircular  canals.  He  quotes 
from  Valsalva,  "Winslow,  Cassebohm,  Haller,  Cotunnius,  Mec- 
kel, and  others,  to  show  tnat  none  of  these  anatomists  had 
traced  nerves  into  the  cochlea.  Dr.  Monro  seems  to  make 
out  a  good  case  for  himself  as  against  Scarpa,  as  far  as  I 
have  been  able  to  determine,  and  to  be  entitled  to  the  credit 
of  having  traced  the  nerves  into  the  cochlea  before  with 
greater  minuteness  than  Scarpa,  and  appears  to  have  been 
correct  in  his  comparative  anatomy. 

*  Three  treatises  on  the  Brain,  the  Eye  and  the  Ear.     Edinburgh  and 
London,  1797. 


PROGEESS  OF  OTOLOGY.  25 

1800]  Mr.  Everard  Home  wrote  an  excellent,  and,  for  its 
time,  exact  account  of  the  lnembraua  tympani  in  a  paper 
for  the  Royal  Society.*  The  measurements  are  accurately 
given,  but  Mr.  Home  supposed  that  the  fibrous  layer  was 
muscular.     He  seems  to  have  been  a  comparative  anatomist 

of  great  ability. 
1806]        Samuel  Thomas  Soemmering,  a  great  name  in  anatom- 
ical science,  contributed  to  otology  by  a  series  of  plates 
of  the  anatomy  of  the  ear,  which  are  almost  as  well  worth 

study  to-day  as  they  were  seventy  years  ago. 
1832]  Henry  Jones  Shrapnel!  contributed  a  series  of  papers 
to  the  London  Medical  Gazette,  f  He  described  the 
membrana  flaccida  of  the  drum-head,  its  nerves,  with  clear- 
ness and  accuracy.  His  description  of  the  former  is  available 
for  the  student  of  the  present  time,  and  Shrapnell's  membrane 
is  probably  firmly  fixed  in  the  nomenclature  of  the  anatomy 

of  the  ear. 
1832]  Thomas  Buchanan,  of  Hull,  brought  out  a  monograph 
illustrative  of  the  anatomy  aud  diseases  of  the  ear. 
His  ideas  as  to  the  importance  of  the  cerumen  produced 
many  errors  in  treatment,  from  which  the  profession  has  not 
yet  fully  recovered.  He  published  four  works ;  the  title  of 
the  last  one  illustrates  what  has  just  been  said  :  "  Physio- 
logical Illustrations  of  the  Organ  of  Hearing,  more  particularly 
of  the   Secretion  of   Cerumen,  and  its  effects  in  rendering 

Auditory  Perception  acute  and  accurate. "% 
1836-39]        The  distinguished  English  surgeon,  T.   Wharton 
Jones,  Esq.,  contributed  to  a  great  cyclopaedia  an  ar- 
ticle on  the  organ  of  hearing,  which  comprised  all  that  was 
known  up  to  that  time,  and  which  is  a  very  valuable  mono- 
graph for  reference^ 
1824-51]        We  are  now,  in  our  review  of  the  investigations  of 
the  anatomy   of  the  ear,  down   nearly  to   our  own 
time;  and  we  come  to  the  familiar  names  of  Husclike,  Ar- 

*  Philosophical  Transactions,  1800.    The  Croonian  Lecture, 
f  Vol.  x.,  1832. 

X  Mr.  Wilde  on  the  early  history  of  Aural  Surgery.     Dublin  Medical 
Journal,  1844,  p.  441. 

§  Cyclopaedia  of  Anatomy  and  Physiology.    Edited  by  Robert  B.  Todd. 


26  A   SKETCH  OF  THE 

nold,    ScJilemn,    Johannes    Mutter,    Breschet,    Bonnafont,     and 

Toynbee. 
1851]  '  Toynbee*  investigated  anew  the  ruembrana  tympani. 
He  especially  added  to  our  knowledge  in  regard  to 
the  fibrous  layer,  and  described,  for  the  first  time,  the  dermoid 
layer.  This  paper  was  published  in  the  Philosophical  Trans- 
actions. It  was  preceded  by  papers  in  the  Medico-Chirur- 
gical  Transactions,  on  the  pathological  anatomy  of  the  ear, 
papers  which  have  given  Toynbee  lasting  fame,  because  they 
did  very  much  to  place  otology  upon  as  sound  a  basis  in 
pathology  as  they  had  been  placed  in  anatomy  by  the  labors 
we  have  enumerated. 

Toynbee  s  statement,  that  the  Eustachian  tube  was  usually 
a  closed  canal,  and  that  muscular  action  was  required  to  open 
it,  led  to  Politzer's  method  of  inflating  the  ear,  of  the  value 
of  which  procedure  more  will  be  said  in  our  review  of  the  pro- 
gress in  therapeutics. 
1856]  Von  Troltscli  began  a  series  of  anatomical  investiga- 
tions, which,  we  may  hope,  have  not  yet  ended.  His 
contributions  relate  to  the  structure  of  the  membrana  tympa- 
ni, the  muscles  of  the  Eustachian  tube,  and  the  pathological 
anatomy  of  the  middle  ear.  He  also,  in  the  course  of  some 
investigations  of  the  cavity  of  the  tympanum  of  the  foetus, 
found  that  it  was  filled  with  a  proliferation  of  the  mucous  mem- 
brane of  the  labyrinth  wall,  which  forms  a  mucous  cushion, 
that  rapidly  lessens  in  size  after  birth.  This  anatomical  fact 
explained  the  frequency  of  inflammations  of  the  middle  ear 

in  young  children. 
1858]         Gerlacli]  followed  Toynbee  in  the  investigation  of 
the  fibrous  layer  of  the  membrana  tympani,  and  showed 
that    in    the    extreme    periphery   the    circular    fibers    were 

wanting. 
1860]        Magnus  investigated  anew   the  articulations  of  the 
ossicula,  and  showed  that  there  was  no  real  joint  be- 
tween the  malleus  and  incus.     He  also  denied  the  voluntary 
or  involuntary  contraction  of  the  tensor  tympani  muscle. 
1862]        Politzer  and  Lucce  published  the  results  of  experi- 

*  Diseases  of  the  Ear.     American  edition. 

f  Schwartze,  Arcliiv  fur  Ohrenheilkunde.     Bd.  I. 


PEOGBESS   OP  OTOLOGY.  27 

rnents,  which  were  supplementary  to  those  of  Miiller,  in  show- 
ing that  the  origin  of  a  certain  crackling  sound  in  the  ear  was 
not  in  the  tendon  of  the  tensor  tympani,  but  in  the  Eusta- 
chian tube. 
1851]  Corti*  an  Italian  anatomist,  reviewed  the  work  of  his 
countrymen  of  the  former  centuries  who  studied  the 
cochlea,  and  divided  the  lamina  spiralis  membranacea  into 
two  different  broad  zones — an  inner  one,  Zona  denticulata; 
and  an  outer,  Zona  pectinata.  He  described  some  peculiar 
bodies  as  teeth,  which  soon  got  the  names  of  Corti' 's  organ, 
and  which  were  subsequently  found  to  be  the  termination  of 
nerves. 

Claudius,  BUtclier,  and  Deiter  followed  Corti  in  investiga- 
tions of  this  part,  which  will  be  fully  noticed  in  discussing  the 

anatomy  of  the  internal  ear.f 
1858]  Hyrtl,  an  anatomist  of  great  industry  and  reputation, 
made  an  important  discovery  of  the  frequency  of  a  thin 
and  porous  bony  covering  to  the  roof  of  the  cavity  of  the 
tympanum,  thus  elucidating  some  cases  of  cerebral  disease 
arising  from  affections  of  the  middle  ear. 

Our  review  now  extends  to  the  time  of  the  publication  of 
the  Archiv  and  the  Monatsschrift  fur  Ohrenheilkunde,  as  well 
as  to  that  of  the  American  Journal ;  the  Archives  of  Oph- 
thalmology and  Otology  ;  to  familiar  ground,  in  the  knowledge 
of  which  the  subsequent  pages  are  written. 

PEOGBESS  IN  ATJEAL  THEEAPEUTICS. 

In  the  earlier  ages  the  progress  in  the  treatment  of  the  ear 
by  no  means  kept  pace  with  the  advance  in  the  knowledge  of 
its  anatomy.  While  the  structure  of  the  organ  was  sufficiently 
well  understood  to  cause  the  investigation  of  its  diseases  to  be 
both  interesting  and  profitable,  the  treatment  was  crude  and 
illogical,  unworthy  of  the  knowledge  which  should  have  been 
its  basis. 

HerodotusJ  says  that  there  were  specialists  in  Egypt,  a  par- 

*  A  Manual  of  Histology  by  Strieker,  p.  1054  (Translation), 
f  For  the  material  for  the  sketch  of  the  preceding  page,  I  am  indebted  to 
Scluoartze,  Archiv  fur  Ohrenheilkunde.     Bd.  I. 

\  Herodotus,  translated  by  Gary.     Euterpe,  p.  125. 


28  A   SKETCH  OF  THE 

ticular  physician  for  each  disease,  but  no  mention  is  made  of 
aurists.  "  The  art  of  medicine  is  thus  divided  amongst  them : 
each  physician  applies  himself  to  one  disease  only,  and  not 
more.  All  places  abound  in  physicians  ;  some  physicians  are 
for  the  eyes,  others  for  the  head,  others  for  the  teeth,  others 
for  the  parts  about  the  belly,  and  others  for  internal  diseases." 

Although  Hippocrates  knew  very  little  about  the  anatomy 
of  the  ear,  he  speaks  at  some  length  of  the  causes  of  aural 
disease.  For  many  of  these  he  must  have  drawn  upon  his 
imagination.  They  were  very  comprehensive,  and  may  prop- 
erly be  said  to  explain  almost  anything.  They  are  such  as 
heat,  cold,  dryness,  moisture,  the  blood,  mucus,  and  the  yel- 
low and  black  bile. 

Hippocrates  considered  internal  inflammation  of  the  ear  as 
essentially  an  inflammation  of  the  head.  He  described  as  a 
very  dangerous  disease,  pains  in  the  ear,  connected  with  high 
fever,  and  if  neither  pus  escaped  from  the  ear  nor  blood  from 
the  nose,  the  death  of  the  patient  usually  occurred  from  the 
ninth  to  the  eleventh  day. 

This  was  probably  the  disease  that  we  now  name  acute  ca- 
tarrh of  the  middle  ear,  and  the  great  medical  philosopher 
was  certainly  right  in  calling  it  a  serious  one. 

Among  all  the  improper  remedies  which  Hippocrates  recom- 
mends to  be  dropped  into  the  ear,  there  is  one  good  one,  al- 
though it  is  very  simple,  which  is  often  thought  to  be  a  sugges- 
tion of  our  own  day ;  that  is,  the  instillation  of  warm  water, 
which  the  great  physician  advises  to  be  done  by  means  of  a 
sponge.  If  this  simple,  but  often  efficacious,  treatment  were 
universally  practised  in  cases  of  acute  inflammations  of  the 
outer  and  middle  ear,  it  would  alleviate  a  great  deal  of  suf- 
fering. 

Hippocrates  seems  to  have  had  an  eye  to  the  effect  upon 
the  patient's  mind,  to  use  no  harsher  term,  if  we  may  believe 
that  the  following  passage  was  not,  as  Lincke  insinuates,  in- 
terpolated* :  "  If  any  person  has  a  pain  in  his  ear,  the  phy- 
sician should  roll  a  bit  of  wool  about  his  finger,  and  then  pour 
some  warm  oil  into  the  ear,  and  then  taking  the  wool  in  the 
hollow  of  his  hand,  and  hold  it  before  the  ear,  in  order  to 
*  Lincke's  Handbuch,  Bd.  II.  p.  5. 


PEOGRESS  OF   OTOLOGY.  29 

make  the  patient  believe  it  has  come  out  of  it.  In  order  that 
the  deception  may  be  complete,  the  wool  should  be  at  once 
thrown  into  the  fire." 

Asclepiades,  a  friend  of  Cicero,  recommended  instillations  for 
the  ear,  of  oil,  in  which  three  or  four  cockroaches,  or  an  Afri- 
can snail  were  cooked,  while  a  piece  of  henbane  in  oil  of  roses, 

or  woman's  milk,  is  to  be  afterwards  added. 
B.C.  44,  A.D.  19]  Celsus  (Aulus  Cornelius)  also  used  a  com- 
posite remedy  which  was  said  to  be  of  service 
in  all  kinds  of  diseases  of  the  ear.  It  was  made  of  cinnamon, 
cassia,  blossoms  of  bulrushes,  castoreum,  white  pepper,  am- 
monia, myrrh,  and  saffron,  as  well  as  of  various  other  agents. 
These  substances  were  all  rubbed  up  with  vinegar,  and  diluted 
with  the  same  agent  when  used. 

Celsus,  in  his  treatise  Be  Medicina,  spoke  in  some  detail  of 
aural  disease.  He  was  perhaps  the  first  to  recommend  vigor- 
ous injections  of  water  in  order  to  remove  foreign  bodies  from 
the  ear,  although  this  proper  recommendation  carries  less 
weight  than  it  would  have  done  had  it  not  been  mingled  with 
a  great  deal  of  bad  advice,  which  shows  that  a  disposition 
to  use  the  simplest  means  for  a  desired  end,  is  not  always 
connected  with  great  learning.  Celsus  recommends  in  obsti- 
nate cases  of  a  foreign  body  in  the  ear,  that  the  patient  should 
be  laid  upon  a  table,  and  upon  the  side  of  the  affected  ear, 
when  the  surgeon  strikes  with  a  hammer  upon  the  table,  in 
order  to  dislodge  the  foreign  body  by  the  concussion. 

Among  the  mass  of  writers  mentioned  by  Lincke  as  being 
before  Galen's  time,  Archigenes  seems  to  have  had  some  cor- 
rect notions.  He  practised  venesection  for  severe  pain  in  the 
ear,  and  employed  purgative  enemas,  warm  baths  to  the  ear, 
especially  by  means  of  a  sponge  dipped  in  hot  water.  He 
warns  against  the  use  of  cold  water.  He  also  has  his  method 
of  removing  a  foreign  body  from  the  ear,  and  recommends  a 
vigorous  shaking  of  the  affected  head.  A  child  is  to  be  seized 
by  the  feet  and  well  shaken,  while  adults  are  to  be  held 
very  much  as  Celsus  proposed ;  that  is,  they  are  to  be  laid 
on  a  table,  while  the  leaf  of  it  nearest  the  head  is  to  be 
repeatedly  opened  and  shut  with  a  slam. 

Archigenes,  like  other  ancient  authorities,  however,  thinks 


30  A   SKETCH  OP  THE 

very  much  of  instillations  of  various  kinds  for  the  relief  of  the 
different  forms  of  deafness.     He  recommends  speaking-tubes 

to  the  deaf. 
A.D.  130-201]  Galen  recognized  the  importance  of  the  ear, 
inasmuch  as  it  lies  so  closely  to  the  head.  Al- 
though his  classifications  of  disease  are  very  minute,  we  do 
not  seem  to  learn  much  from  his  writings,  except  the  value  of 
agents  that  will  excite  the  secretions  of  the  nose  and  mouth, 
which  he  recommends  in  aural  disease.  He  complains  of  the 
empirical  practices  of  his  predecessors  in  ordering  now  cold 
and  now  warm  agents,  now  sweet  and  now  sour  ones. 

He  also  tells  of  a  poor  patient  of  some  less  learned,  or  less 
practical  man  than  himself,  who,  in  accordance  with  advice, 
used  black  pepper  as  a  local  means  of  treatment  for  an  in- 
named  ear,  and  whose  sufferings  were  so  much  augmented, 
that  he  came  near  hanging  himself. 

Galen  objects  to  the  common  use  of  opium,  which  seems  to 
have  been  employed  very  much  in  relieving  the  pain  of  aural 
disease. 

Tinnitus  aurium,  according  to  Galen,  was  due  in  some 
cases  to  exhalations  from  the  stomach,  and  in  others  to  in- 
creased sensitiveness  of  the  ears.  Both  of  these  causes  cer- 
tainly leave  much  to  be  wished  for,  in  the  way  of  exact  knowl- 
edge, as  to  the  nature  of  this  distressing  symptom. 

It  would  be  tedious  in  the  extreme  to  follow  Galen  through 
his  classification  of  diseases  of  the  ear,  and  remedies  for  them. 
Like  his  predecessors  and  contemporaries,  he  was  not  will- 
ing to  admit  that  there  were  some  diseases  for  which  remedies 
were  useless,  so  far  as  their  knowledge  went.  The  aural  pre- 
scriptions of  the  ancients  may  well  be  compared  to  the 
mitrailleuse,  dangerous  far  and  wide. 

Ccelius  Aureliamis,  a  successor  of  Galen,  stands  out  prom- 
inently from  the  absurd  theorizers  of  his  time,  in  his  clear 
delineations  of  pain  in  the  ear,  and  his  sensible  remedies  for 
it — leeches,  cups,  poultices,  mustard-plasters,  and  so  on. 

Apollonius,  quoted  by  Galen,  took  out  foreign  bodies  with 
ear-spoons,  forceps,  hooks,  etc.,  which  were  enveloped  in  wool 
and  dipped  in  turpentine.  He  softened  ear-wax  with  saltpetre 
in  vinegar,  and  then  removed  it  with  lukewarm  water  or  oil. 


PEOGEESS   OF  OTOLOGY.  31 

About  this  time  we  read  of  the  materia  medica  of  Marcd- 
lus,  who  gives  us  a  glimpse  of  the  popular  remedies  of  the  day. 
Frogs'  fat  is  recommended  for  pain  in  the  ear ;  the  urine  of 
pigs,  of  children  and  men,  and  the  blood  of  young  chickens, 
for  an  ulcer  in  the  ear ;  for  worms  in  the  organ,  the  saliva 
of  a  hungry  man,  and  so  on. 

We  see  a  great  deal  in  the  ancient  literature,  of  worms 
in  the  ear ;  so  that  we  must  conclude  that  they  were  much 
more  commonly  found  in  the  olden  time  than  with  us.  This 
was  probably  due  to  the  fact  that  cases  of  neglected  suppura- 
tion were  very  frequent,  and  that  living  larvae  were  thus  often 

developed. 
600  A.D.]  The  famous  surgeon  and  obstetrician,  Paulus 
JEginiia,  who  flourished  in  the  seventh  century, 
should  be  remembered  as  a  contributor  to  the  surgery  of 
otology.  He  expended  much  energy  on  the  subject  of  foreign 
bodies  in  the  ear,  a  field  which  has  unfortunately  always  suf- 
fered from  surgeons  over-anxious  for  operations.  He  suggests 
a  method  for  their  removal,  which,  when  all  other  means  fail, 
is  still  to  be  thought  of  in  our  day.  It  is  an  incision  behind 
the  ear,  to  detach  the  auricle  from  the  canal.  We  are  thus 
enabled  to  get  at  the  foreign  body  very  readily.  Hippocrates 
is  said  to  have  also  recommended  this  procedure. 

According  to  Lincke,  the  Arabians  got  their  knowledge  of 
otology,  whatever  it  was,  from  the  Greeks,  of  whom  Galen 
was  the  chief  authority  ;  so  that  we  can  only  add  a  few  more 
absurd  remedies  as  their  contribution  to  knowledge :  for 
deafness,  the  brain  of  a  lion  mixed  with  oil  (the  brain,  not  the 
lion,)  is  advised  by  Bhazes.  Serapion  advises  instillation  of 
woman's  milk  for  the  cure  of  ear-ache  in  children ;  and  he 
gives  the  important  caution  that  if  it  be  a  boy  who  is  affected, 
the  milk  must  be  that  of  a  woman  who  is  nursing  a  female 
infant. 

As  we  have  seen,  in  noticing  the  progress  in  our  knowledge 
of  the  anatomy  of  the  ear,  the  centuries  from  Galen  to  Val- 
salva were  dark  ages  for  our  science.  Lincke  says  :  "  Otol- 
ogy remained  at  the  same  point  at  which  the  Grecian,  Ro- 
man, and  Arabian  physicians  had  left  it."  In  Lincke's  own 
list  of  the  progress  of  these  centuries  we  find  traces  of  ignor- 


32  A   SKETCH  OF  THE 

ance  and  empiricism  only.  One  author  named  Gadesden  rec- 
ommends that,  in  cases  of  inflammation  of  the  ear,  one  of  the 
lower  classes  be  hired  to  suck  out,  by  means  of  a  tube  placed 
in  the  meatus  externus,  all  the  morbid  material  of  the  ear ; 
and  this  is  said  to  be  a  cure  for  all  kinds  of  deafness,  not  even 
excepting  that  from  a  purulent  affection  of  the  organ.  Lincke 
believes  that  Peter  de  la  Cerlata  was  the  first  to  use  a  specu- 
lum for  widening  the  auditory  canal  for  purposes  of  inspec- 
tion.* 
1560]  Johannes  Arcularius  gave  some  sensible  rules  for 
the  management  of  aural  disease.  He  declaimed,  for 
instance,  against  the  indiscriminate  practice  of  stuffing  the 
ear  with  cotton ;  but  he  advised  an  extremely  peculiar 
means  of  extracting  a  foreign  body  from  the  ear.  The 
head  of  a  lizard  was  to  be  cut  off,  placed  in  the  affected  ear, 
and  allowed  to  remain  there  for  three  hours.  The  animal  is 
then  to  be  removed,  when  the  foreign  body  will  be  found  in 

its  mouth. 

1560]        Alexander  Benedetti  recommends,  as  a  remedy  for  pain 

in  the  ear,  the  semen  of  a  boar,  which  is  to  be  carefully 

taken  from  the  vagina  of  a  sow,  before  she  has  dropped  it  upon 

the  ground.     This,  however,  is  the  suggestion  of  a  writer  on 

general  medicine,  and  not  on  otology. 
1523-1582]  Gabriel  Fallopius,  in  this  century,  seems  to  be 
entitled  to  the  honor  of  having  first  taught  that  a 
discharge  of  pus  from  the  ear  of  a  child  should  not  be  meddled 
with ;  for  as  Fallopius  gravely  taught,  and  as  has  been  gravely 
repeated  by  his  legitimate  successors  for  two  hundred  and 
seventy-three  years,  this  discharge  of  pus  is  an  effort  of  na- 
ture to  throw  morbid  material  out  of  the  head  through 
the  ear.  The  otorrhcea  of  adults,  according  to  Fallopius,  is 
also  a  discharge  from  the  brain,  and  should  not  be  treated  by 
astringents,  but  with  mild,  cleansing  remedies.  He  used  an 
aural  speculum,   and  employed    sulphuric   acid   to  remove 

polypi. 
1600]        In  the  seventeenth  century  we  hear  of  De  Vigo,  body 
surgeon  to  Pope  Julius  II.,  curing  his  Holiness  of  a  very 

*  The  passage  quoted  to  sustain  this  view  is  "per  inspectionem  ad  solen 
trahendo  aurem  et  ampliando  cum  speculo  aut  alio  instrumento" 


PEOGEESS   OF  OTOLOGY.  33 

obstinate  abscess  of  the  right  ear,  by  means  of  a  mixture,  or 
liniment,  of  3  ij  of  oil  of  eggs  with  3  iij  of  oil  of  roses.  What 
kind  of  an  abscess  this  was,  or  where  it  was  situated,  Linclce 
does  not  tell  us. 

In  the  latter  half  of  the  sixteenth  century  a  certain  Capi- 
vacci  seems  to  have  deviated  a  little  from  the  errors  of  his  pre- 
decessors. He  speaks  with  more  precision  of  aural  disease. 
He  describes  thickening,  ulcers,  and  cicatrices  of  the  mem- 
brana  tympani,  and  says  that  deafness  which  arises  from  an 
affection  of  the  nerve  or  labyrinth  is  incurable — a  declaration 
in  which  his  successors,  three  hundred  years  after  him,  are 
forced  to  unite.  Capivacci  also  describes  a  method  of  making 
a  differential  diagnosis  between  the  diseases  of  the  peripheric 
and  of  the  central  parts  of  the  organ  of  hearing.  One  end  of 
an  iron  rod,  an  ell  in  length,  is  put  between  the  teeth  of 
the  patient,  while  the  other  is  placed  upon  a  keyed  musical 
instrument.  If  he  could  distinguish  the  tones  produced  by 
the  vibrations  of  the  keys  of  the  instrument,  his  deafness 
depended  upon  some  lesion  of  the  membrana  tympani ;  if  not, 
it  was  an  affection  of  the  nerve.  Here  we  see  glimpses  of  de- 
duction from  the  anatomical  knowledge  of  the  time. 

Peter  Forest,  who  must  have  been  an  Englishman,  judging 
from  his  name,  but  who  practised  in  Home  in  this  century, 
to  whose  works  Lincke  gives  no  definite  reference,  collected  fif- 
teen cases  of  aural  disease  that  seem  to  have  been  carefully  ob- 
served. One  is  a  case  of  disease  of  the  ear,  ending  in  an  af- 
fection of  the  brain  and  death.  He  speaks  of  pain  in  the  ear 
caused  by  the  rays  of  the  sun,  and  he  tells  a  wonderful  story 
of  a  female  deaf  for  seven  years — so  deaf  that  she  could  not 
hear  a  clock  strike — who,  being  advised  by  that  character  so 
common  in  medical  scenes,  an  old  woman,  to  put  some  musk 
in  her  ear,  did  so,  and  was  cured.  He  also  tells  how  his 
teacher,  Gisbert  Horst,  the  director  of  a  hospital  in  Borne,  used 
to  heal  deafness  with  water  that  was  distilled  over  a  young 
mouse  having  no  hair. 

We  trace  one  of  the  delusions  that  still  lingers  among  us — 

namely,  that  the  hearing  is  completely  destroyed  when  the 

membrana  tympani  is  broken — to  a  writer  named  HerciHes 

Sassonia,  who  lived  in  this  century.     He  also  had  the  peculiar 

3 


34  A  SKETCH  OF  THE 

notion  that  patients  always  spoke  in  a  low  tone  when  the 
disease  of  the  ear  was  seated  in  the  auditory  nerve,  because 
the  nerve  supplying  the  tongue,  a  branch  of  the  fifth,  was  at 
the  same  time  affected.  In  deafness  arising  from  venereal 
disease,  blisters  behind  the  ear,  and  a  mixture  of  oil  of  guaia- 
cum  and  hydrochloric  acid,  as  a  local  application,  of  which 

the  patient  drank  a  little,  were  highly  spoken  of. 
1510-1590]        The   great  Frenchman,  the  father  of  modern 
surgery,  Ambrosius  Pare,  figures  in  otological  his- 
tory as  the  first  one  to  employ  a  syringe  for  cleansing  the 

ear. 

1597]        Caspar  Tagliacottzi,  of  Bologna,  who  did  so  much  for 

plastic  surgery,  did  not  neglect  the  ear,  but  attempted  to 

restore  the  auricle  by  taking  integument  from  the  adjacent 

skin.     He  relates  one  case  of  a  Benedictine  Monk,  where  he 

had  done  this  with  success.* 
1690]  Although  the  aural  speculum  had  been  used  a  hun- 
dred years  before,  we  find  a  certain  Johann  Hartman  very 
unwilling  to  use  it ;  for  he  seems  to  advise  the  detection  of 
inspissated  cerumen  by  the  following  simple  method.  He 
placed  a  curved  silver  tube  into  the  ear,  and  blew  through  it. 
If  the  patient  felt  the  breath  to  be  cold,  the  deafness  did  not 
proceed  from  impaction  of  wax.  In  our  day  the  detail  of 
this  method  is  sometimes  simplified  without  altering  the 
principle ;  that  is  to  say,  a  probe  is  used  to  see  if  wax  is  in 
the  ear.  Through  all  this  century,  the  seventeenth,  there 
are  numerous  volumes  on  the  treatment  of  the  ear,  but  they 
all  tread  through  the  barren  waste  of  drops  and  decoctions, 
theories,  nomenclatures,  and  rank  empiricism. 

Lusitanus  gives  an  amusing  explanation  of  the  practice  of 
cutting  off  the  ears  of  thieves.  He  said  that  such  treatment 
rendered  them  incapable  of  propagating  their  kind,  and  hence 
no  more  thieves  could  be  born  of  them.  He  founded  this 
opinion  on  the  statement  of  Hippocrates  that  the  division  of 
the  veins  behind  the  ear  rendered  a  man  sterile,  because  the 

*  The  efforts  made  to  instruct  and  to  cure  the  deaf  and  dumb,  which  were 
first  thoroughly  incited  in  this  half  of  the  sixteenth  century,  we  leave  for  a 
fuller  discussion  in  the  chapter  on  deaf-muteism. 


PROGRESS  OF  OTOLOGY.  35 

semen,  which  was  generated  in  the  brain,  could  no  longer  pass 
down  to  the  genitals. 

Johann  Baptista  van  Helmont,  evidently  a  Belgian,  casts 
away  the  theory  that  had  so  long  prevailed,  of  deafness  being 
caused  by  ascending  exhalations,  and  clears  up  the  whole 
matter  by  ascribing  it  to  the  work  of  the  devil,  or  other  evil 

spirits. 

1640]        Marcus  Bonze  gives  us  the  first  idea  of  an  artificial 

membrana  tympani,  by  proposing  to  place  a  tube  of 

ivory  in  the  auditory  canal,  the  end  of  which  is  covered  by  a 

bit  of  pig's  bladder,  as  a  protection  to  the  exposed  ear,  when 

the  membrana  tympani  was  lost  by  ulceration. 
1646]  The  renowned  surgeon,  Fabricius  of  Hilden,  or  Fabri- 
cius Hildanus,  so  called  to  distinguish  him  from  Fabri- 
cius of  Acquapendente,  contributed  somewhat  to  the  surgery  of 
the  ear.  He  invented  an  instrument  for  extracting  foreign 
bodies  from  the  ear,  as,  indeed,  every  surgeon  of  eminence 
seems  to  have  thought  it  his  duty  to  do.  He  also  wrote  of 
the  removal  of  aural  polypi. 

In  the  latter  half  of  the  seventeenth  century,  Thomas  Willis 
attempted  to  prove,  by  experiments  on  animals,  that  total 
deafness  does  not  ensue  when  the  membrana  tympani  is 
destroyed.  He  also  made  some  interesting  observations  on  deaf 
persons  who  only  heard  in  the  midst  of  a  noise.  Yon  Troltsch 
quotes  one  of  these  cases  in  his  text-book,*  that  of  a  woman 
who  could  only  hear  her  husband  when  a  servant  was  beating 
a  drum.  The  conversations  in  that  family  were  probably  not 
very  protracted.  This  kind  of  impairment  of  hearing,  which 
was  called  paracusis  Willisiana,  was  referred  by  its  describer 
to  a  relaxation  of  the  membrana  tympani,  the  normal  tension 
being  restored  by  the  noise,  or  vibrations  of  the  atmos- 
phere. 
1683]  Du  Verney,  known  by  his  labors  in  the  anatomy  of  the 
organ,  and  his  work  on  the  diseases  of  the  ear,  contributed 
very  little  to  sound  knowledge,  although  he  made  an  attempt 
to  arrange  the  diseases  in  accordance  with  the  anatomy.  He, 
however,  disputed  the  generally  accepted  opinion  that  a  dis- 

*  Diseases  of  the  Ear,  American  translation,  2d  edition,  p.  256. 


36  A   SKETCH   OF  THE 

charge  of  pus  from  the  ear  came  from  the  brain,  and  showed 
that  the  meatus  auditorius  internus  was  closed  by  the  auditory 
nerve,  and  that  ihe  pus  must  pass  through  the  cochlea  and 
the  fenestra  ovalis  rotunda,  before  it  could  get  into  the  exter- 
nal auditory  canal. 

Du  Yerney  modified  Hippocrates'  suggestion  to  get  at  a 
foreign  body  not  otherwise  easily  removed,  by  making  an 
opening  behind  the  ear,  and  recommended  that  the  incision 
be  made  upon  the  upper  side,  because  the  vessels  are  smaller 
in  this  position.  He  thus  anticipates  Von  Troltsch,  who  made 
the  same  modification  of  the  original  suggestion  nearly  two 
hundred  years  later.* 

We  still  continue,  in  the  works  upon  the  ear  that  appear  in 
this  century,  to  hear  much  of  worms,  or  living  larvae,  in  the  ear 
— a  state  of  things,  however  common  among  the  ancients,  that 
is  now  very  rare,  because  suppurating  ears  are  usually  cleansed. 
The  disgusting  and  magical  ear-drops  of  the  early  and  dark 
ages  are  still  used  in  this  latter  part  of  the  seventeenth  century. 
Thus  one  writer  records  that  a  Capuchin  monk  mixed  the  urine 
of  a  female  donkey,  that  had  brought  forth  but  once,  with  that 
of  a  male  hare,  of  a  wrolf,  or  in  case  of  the  absence  of  the  latter, 
of  an  entirely  white  goat,  warmed  it,  and  adding  a  little  oil  of 
caraway,  used  it  as  drops  for  the  ear.  Urine  of  the  various 
animals  figures  largely  among  the  ear-drops  of  the  period. 
Paullini,  one  of  the  writers  of  the  day,  is  in  doubt,  however, 
whether  it  is  proper  that  women  should  use  the  renal  secretion 
of  dogs  as  a  remedy  for  deafness. 

We  begin  to  hear  more  in  the  latter  part  of  the  seventeenth 
century  of  the  education  of  the  deaf  and  dumb,  but  it  is  min- 
gled with  much  that  is  absurd  in  attempts  at  treatment.  The 
great  error  was  then  made,  as  it  often  is  now,  of  supposing 
that  the  diseases  of  the  ear  which  produced  deaf-muteism  were 
of  a  different  nature  from  those  which  in  the  adult  caused 
deafness  only. 

John  Wallis,  an  Englishman,  was  perhaps  the  first  to  in- 
struct a  deaf-mute  to  speak — which  he  did,  and  that  very  well. 
The  case  was  one  of  acquired  deaf-muteism,  the  patient  having 

*  Diseases  of  the  Ear.     American  translation,  p.  488. 


PROGRESS   OP  OTOLOGY.  37 

lost  his  hearing  at  eight  years  of  age ;  but  he  became  able  to 
read  the  Bible  aloud,  and  to  converse  with  some  fluency. 

Lincke  begins  his  account  of  the  progress  of  otology  in  the 
eighteenth  century  with  the  lament  that  it  did  not  keep  pace 
with  the  anatomical  investigations  of  the  organ,  which  had 
been  brought  to  such  a  high  point  by  the  labors  of  Valsalva, 
Gassebohm,  Cotugno,  and  Scarpa,  and  he  says  that  Otology  would 
have  advanced  very  much  faster  had  Antoine  Marie  Valsalva 
devoted  himself  more  to  its  prosecution.  But  Valsalva  did 
much  to  give  us  correct  notions  in  regard  to  the  diseases  of 
the  ear.  He  adduced  cases  where  the  membrana  tympani 
had  been  restored.  He  showed  that  the  hearing  power  is 
merely  impaired,  not  lost,  by  a  perforation  of  the  membrana 
tympani.  He  recognized  auchylosis  of  the  base  of  the  stapes 
as  a  cause  of  deafness.  He  gave  us  the  Valsalvian  experi- 
ment, the  mode  of  forcing  air  through  the  Eustachian  tube  by 
a  forced  expiration  with  the  mouth  and  nostrils  closed,  and 
he  advises  it  as  the  best  means  of  cleansing  the  middle  ear 
from  pus.  He  proved  that  the  cavity  of  the  tympanum  is 
connected  to  the  cells  of  the  mastoid  process,  by  a  case  in 
which  he  injected  the  former  through  a  fistulous  opening  in 
the  latter.*  He  also  showed  that  stoppage  of  the  Eustachian 
tube  is  often  a  cause  of  deafness.  This  is  certainly  a  re- 
freshing catalogue  after  we  have  been  wading  through  the 
disgusting  empiricism  of  the  centuries  before. 

Valsalva's  century  is,  however,  also  cursed  with  theoretic 
treatises  on  aural  disease,  such  as  that  of  one  Frederick 
Hoffmann,  who  goes  on,  in  the  good  old  way,  with  instillations 
of  wonderfully  compounded  ear-drops.  Lincke  mentions 
numerous  inaugural  dissertations  of  this  time,  but  they  relate 
chiefly  to  cases  that  were  not  properly  understood  by  the  re- 
porters of  them  ;  and  these  authors,  as  well  as  their  theses,  are 

deservedly  forgotten. 
1774]        J.  L.  Petit  in  a  work  upon  surgical  diseases,  reports 
many  interesting  cases  of  caries  of  the  temporal  bone. 
In  one  case  of  suppuration  in  the  ear,  with  caries  of  the  mas- 
toid, he  advised  that  this  part  should  be  cut  down  upon  and 

*  As  I  have  elsewhere  shown,  this  case  was  for  a  long  time  supposed  to 
be  one  of  perforation  of  the  mastoid.   Vide  chapter  on  the  disease  of  the  mastoid. 


38  A  SKETCH  OF  THE 

trepanned.  His  advice  was  not  followed  and  the  patient  died. 
He  also  relates  cases  where  this  operation  was  successfully 
performed,  and  he  must  therefore  be  considered  as  the  origi- 
nator of  this  valuable  procedure.* 
1735]  We  then  come  to  the  famous  postmaster  of  Versailles, 
Gkiyot,  who  first  injected  the  Eustachian  tube.  His  own 
hearing  was  impaired,  and  in  order  to  relieve  it  he  introduced 
an  angular  tube  of  tin  through  the  mouth,  opposite  (gegen),  not 
into,  the  Eustachian  tube.  The  distal  extremity  of  this  instru- 
ment was  attached  to  a  leathern  tube.  This  was  connected  to 
the  reservoir  of  two  small  pumps,  which  were  moved  by  two 
cranks  and  a  wheel  fastened  in  machinery,  by  means  of  which 
he  forced  fluid  through  a  curved  pewter  tube,  placed  behind 
the  uvula,  into,  or  about,  the  mouth  of  his  Eustachian  tube, 

and  removed  the  impairment  of  hearing. 
1735]  Bech,^  who  quotes  from  the  Hist  de  I 'Acad,  des  Sci- 
ences, thinks  that  Guyot  washed  out  the  mouth  of  the  Eus- 
tachian tube.  We  now  know  that  the  procedure  alone  is  a 
very  valuable  one.  I  regret  very  much  that  I  cannot  get 
access  to  Guyot' s  original  report  to  the  French  Academy. 

About  fifteen  years  later  Archibald  Cleland,  an  English 
physician,  revised  the  operation  of  catheterization  of  the  Eus- 
tachian tube,  and  introduced  a  tube  through  the  nose,  which 
was  a  much  more  practicable  method  than  that  of  Guyot. 
His  contemporaries  seem  to  have  paid  little  attention  to  his 
suggestions,  for  Van  Sivieten  recommends  catheterization  of 
the  tube  through  the  mouth  as  a  possible  operation.  Wilde 
attempts  to  claim  the  use  of  the  catheter  as  a  British  dis- 
covery. He  makes  Guyot  a  mere  suggester  of  the  operation 
of  catheterization,  but  I  think  the  evidence  is  in  favor  of  the 

French  postmaster. 
1755]  Jonathan  Wathan,  an  English  author,  reported  cases 
of  restoration  of  hearing  by  means  of  catheterization  of 
the  tube  through  the  nose.  His  paper  is  in  the  Philosophical 
Transactions  of  the  Royal  Society.  He  seems  not  to  have 
known  of  Cleland's  labors  in  the  same  direction. 

*  For  a  full  account  of  the  operations  on  the  mastoid,  see  the  appropriate 
chapter  in  this  work. 

f  Die  Krankheiten  des  Gehoerorganes,  1827,  p.  21. 


PEOGKESS  OF  OTOLOGY.  39 

Archibald  Cleland  still  farther  advanced  the  science  of 
otology  by  introducing  a  three-inch  convex  lens,  with  a  han- 
dle, as  a  means  of  examining  the  ear.  The  ear  was  illumin- 
ated by  a  waxlight  attached  to  the  lens. 
1748]  Julian  Busson  proposed,  in  rather  an  undecided  way, 
to  perforate  the  membrana  tympani,  in  order  to  remove 
collections  of  pus  from  behind  it ;  but,  as  this  was  a  very  dan- 
gerous operation,  he  advised  the  inhalation  of  vapors  through 
the  mouth  and  nose,  and  then  that  they  be  forced  into  the 
Eustachian  tube  by  means  of  Valsalva's  method,  as  he  thought 
that  the  pus  might  thus  be  driven  out  of  the  middle  ear. 

The  surgeons,  after  the  seemingly  complete  failure  of  phy- 
sicians to  successfully  treat  diseases  of  the  ear,  animated  by 
the  invention  of  the  Eustachian  catheter  and  Petit's  operation 
for  perforation  of  the  mastoid,  seem  to  have  been  exceedingly 
active  in  otology  during  the  latter  half  of  the  eighteenth  cen- 
tury. Antoine  Petit,  as  well  as  Cleland,  recommended  the  use  of 
an  instrument  through  the  nose  instead  of  through  the  mouth, 
as  proposed  by  Guyot,  and  injections  through  the  tube  are 
everywhere  recommended  in  their  writings. 

The  successful  cases  which  were  reported  about  this  time 
were  usually  among  young  persons.  The  reason  that  the 
Eustachian  catheter  fell  into  such  disrepute  can  be  found  in 
the  fact,  that  it  was  used  in  chronic  cases,  in  which  the  prog- 
nosis should  have  been  pronounced  bad  or  hopeless  from  the 
beginning,  and  a  natural  disappointment  occurred  from  the 
want  of  success. 

One  very  careful  soul  who  seems  to  have  been  in  great  hor- 
ror of  the  operation,  proposed  that  patients  upon  whom  the 
catheter  was  to  be  used  should  have  the  hairs  of  the  nostrils 
removed,  and  a  day  before  the  operation  that  lukewarm  milk, 
or  a  linseed-meal  mixture,  or  the  like,  should  be  drawn  into 

the  nostrils,  so  as  to  make  the  parts  more  pliable. 
1792]  The  operation  of  perforation  or  trephining  the  mas- 
toid process  fell  into  great  disrepute  because  a  Danish 
surgeon,  Berger,  caused  it  to  be  performed  upon  hiinself, 
and  very  improperly,  for  "  deafness  which  had  been  years  in 
occurring,  and  which  was  accompanied  by  vertigo,  headache, 
and  noise  in  both  ears."     Meningitis  resulted,  and  the  pa- 


40  A  SKETCH  OF  THE 

tient  died  in  a  few  days.     This  put  a  stop  to  the  performance 
of  this  very  useful  and  necessary  operation,  until  it  was  lately 

revived,  chiefly  by  German  and  American  surgeons. 
1800]  Everard  Home*  by  his  writings,  suggested  to  Sir 
Astley  Cooper  the  operation  of  perforation  of  the  mem- 
brana  tympani,  which  the  great  English  surgeon  performed 
successfully  in  four  cases.  The  history  of  the  rise  and  fall, 
and  revival  of  this  operation  will  be  found  in  the  chapter  on 
chronic  non-suppuration  of  the  middle  ear. 

John  Cunningham  Saunders^  wrote  a  work  on  the  ear,  its 
anatomy  and  diseases,  which  went  through  several  editions  in 
England,  and  one  in  America. 

It  is  a  brief,  but  scientific  treatise,  and  far  beyond  its  pre- 
decessors. It  is  characterized  by  simplicity,  and  is  without 
the  absurdities  of  the  older  text-books.  It  is  deficient  in  de- 
scriptions of  the  methods  of  examining  the  drum-head,  and 
teaches  the  erroneous  doctrine  that  it  is  proper  to  probe  a 
membrana  tympani  to  see  if  it  be  intact. 

It  should  be  remembered  that  Saunders  advised  paracen- 
tisis  of  the  membrana  tympani  in  cases  of  acute  suppura- 
tion of  the  tympanum^ — an  operation  that  was  revived  by 
Schwartze  a  few  years  ago. 

He  says  :  "  But  let  it  be  admitted  that  the  tympanum  has 
suppurated,  ought  the  membrana  tympani  to  be  abandoned 
to  a  casual  ulceration,  or  is  it  better  to  open  it  by  art  ?  I  am 
inclined  to  prefer  the  latter,  and  if  I  can  be  assured,  by 
any  symptom,  that  suppuration  has  taken  place,  I  should 
not  hesitate  to  make  a  small  perforation  of  the  membrana 
tympani,  and  to  repeat  it,  if  necessary,  taking,  at  the  same 
time,  every  precaution  to  suppress  the  fresh  collection  of 
matter." 

Saunders  speaks  wisely  against  the  objections  made  to 
checking  a  purulent  discharge  from  the  ears,  and  shows  that 
disease  of  the  brain  is  very  apt  to  follow  a  neglected  chronic 
suppuration,  and  he  gives  some  interesting  illustrative  cases. 

*  Philosophical  Transactions,  1800. 

f  The  Anatomy  of  the  Human  Ear,  &c.     Edited  by  Wm.  Price,  M.D., 
Philadelphia,  1827. 
%  Ibid.,  p.  59. 


PEOGRESS   OP   OTOLOGY.  41 

The  book  is  very  deficient  in  its  treatment  of  the  Eustachian 
tube.  Thus  early  do  we  find,  in  spite  of  Cleland's  and  Wa- 
than's  teachings,  the  English  prejudice  against  the  use  of  the 

catheter,  which  has  only  lately  been  overcome. 
1817]        J.  H.  Curtis  also  published  a  book  on  the  ear,*  but 
it  added  nothing  to  our  knowledge,  being  a  feeble  imita- 
tion of  the  work  of  Saunders. 
1819]        J.  A.  Saissy,  of  Lyons,  devoted  the  last  twelve  years 
of  his  life  to  the  study  of  aural  disease.     He  published  a 
work  on  the  ear,  which  attained  the  honor  of  a  place  in  the 
"  Dictionnaire  des  Sciences  Medicales."    This  work  was  trans- 
lated into  English  by  Nathan  B.  Smith,  the  celebrated  Ameri- 
can surgeon.f 
182 i]        /.  M.  G.  Itard,  Physician  to  the  Royal   Deaf  and 
Dumb  Institution  in  Paris,   also   publishes  a  treatise, 
which  was  translated  into  German, $  and  which  did  much  in 
the  pioneer  work  of  clearing  up  the  undergrowth  of  centuries 
of  neglect. 

Then  followed  Deleau,  on  the  diseases  of  the  middle  ear 
and  on  perforation  of  the  membrana  tympani,  an  operation 

for  which  he  claimed  more  than  it  deserved. 
1827]        Karl  Joseph  Beck,  of  Freiburg,  published  a  Hand- 
book of  the  Diseases  of  the  Ear.§     It  is  a  succinct  and 
carefully  written  compendium  of  what  was  then  known  in  this 
department   of  science,  and  has  a  very  good  bibliography, 
with  the  exception  of  the  fact  that  the  names  of  English  au- 
thors are  very  often  misspelled. 
1833]         Wilhelm  Kramer,  of  Berlin,  an  author  who  still  lives 
in  a  vigorous  old  age,  brought  out  a  work  which  was 
animated  by  the  true  scientific  spirit,  and  which  greatly  sim- 
plified the  practice  of  otology.     He  has  since  then  published 
a  number  of  volumes. 

He  introduced  a  valvular  handled  speculum,  that  was  an 
improvement  upon  the  very  clumsy  ones  hitherto  in  use.     He 

*  A  Treatise  on  the  Physiology  and  Diseases  of  the  Ear,  hy  John  Harrison 
Curtis,  Esq.     3d  Edition.     London,  1823. 

f  An  Essay  on  tbe  Diseases  of  the  Internal  Ear.    Baltimore,  1S29. 

%  Die  Krankheiten  des  Ohres  nud  des  Gehors. 

§  Die  Krankheiten  des  Gehoerorganes.     Heidelberg  und  Leipzig. 


42  A   SKETCH   OF  THE 

also  gave  us  the  air-press,  by  which  air  or  vapors  could  be 
introduced  through  the  Eustachian  tube  into  the  middle  ear. 

In  speaking  of  the  practices  of  his  predecessors,  the  in- 
tolerance of  Kramer's  spirit  is  seen — an  intolerance  which  is 
painfully  manifest  in  his  later  works.*  In  1860  he  speaks  of 
the  writings  of  Hinton  of  London — a  writer  whom,  I  am  sure, 
all  my  readers  will  learn  to  respect,  "  as  in  every  respect 
unimportant,"  while  Toynbee's  pathological  investigations,  to 
which  science  is  so  much  indebted,,  are  actually  treated  with 
sneers.  In  1865,  Kramer  published  a  monograph,!  which  is 
essentially  a  review  in  a  very  unfriendly  spirit  of  the  labors 
of  Toynbee,  "Wilde,  Von  Troltsch,  Erhard,  Yoltolini,  and 
others,  of  whose  writings  I  shall  soon  speak.  What  good 
work  Dr.  Kramer  actually  did  for  otology  in  his  younger 
days  has  been  overshadowed  by  his  subsequent  writings. 
In  spite,  of  what  I  am  almost  inclined  to  call  common  sense, 
he  still  persists  in  rejecting  the  modern  method  of  investi- 
gation, as  well  as  the  results  of  examinations  of  ears  re- 
moved from  persons  who  have  been  deaf.  He  still  con- 
tinues to  use  the  handled  bi-valved  speculum,  with  sunlight 
as  the  only  source  of  illumination,  and  on  cloudy  days  sends 
away  patients  without  examination ;  and  because  Toynbee 
made  post-mortem  examinations  of  many  ears  of  persons  whom 
he  had  not  seen  during  life,  Kramer  rejects  all  pathological 
investigations,  except  experiments  conducted  upon  a  dead 
body  or  a  glass  model.  He  speaks  of  Politzer's  method  of 
inflating  the  middle  ear,  "  as  a  miserable  resort  in  cases  of 
necessity,  the  employment  of  which,  all  pompous  commenda- 
tions to  the  contrary  notwithstanding,  stamps  him  who  uses 
it  with  want  of  skill  in  the  introduction  of  the  catheter." 
Again  he  calls  Toynbee,  in  his  work  published  in  1867,t  an(l 
this  after  Toynbee  had  lost  his  life  in  experiments  as  to  the 
effect  of  chloroform  and  lrydrocyanic  acid,  "  a  very  poor  aural 
surgeon."     "Ein  miserabler  Ohren-arzt." 

These  are  fair  specimens  of  Dr.  Kramer's  style  in  dealing 
with  an  opponent,  with  any  one  who  claims  to  have  accom- 

*  Ohrenheilkunde  der  Gegenwart,  1860.     Berlin,  1861. 

f  Okrenkrankheiten  und  Ohrenartze  in  England  and  Deutschland. 

%  Handbucli  der  Ohrenheilkunde,  p.  44.     Berlin,  1867. 


PEOGEESS   OP  OTOLOGY.  43 

plished  anything  for  aural  pathology  and  therapeutics  in  any 
other  way  than  by  the  employment  of  his  catheters,  Ids 
bougies,  and  his  valvular-handled  speculum. 

In  this  review  of  what  has  been  done  to  bring  otology  up 
to  its  present  position,  I  have  been  compelled  to  notice  the 
difficulties  with  which  the  advance  of  the  science  has  been 
obliged  to  contend  in  the  way  of  improper  and  unjust  criticism, 
from  one  who,  in  this  country  and  England,  has  acquired  the 
reputation  of  a  safe  guide  and  leader  in  this  part  of  the  field 

of  medicine. 
1841]  George  Pilcher  wrote  an  essay  on  the  ear,  which  re- 
ceived the  Fothergillian  gold  medal  from  the  Medical 
Society  of  London.  It  is  a  valuable  compilation.  The  sec- 
tion on  foreign  bodies  in  the  meatus  is  full  of  warning  interest. 
There  is,  however,  very  little  of  the  author's  own  experience 
in  the  volume.* 

In  1841,  a  gentleman  from  New  York,  consulted  Dr.  James 
Yearsley,  of  London,  in  regard  to  his  deafness,  who  informed 
Dr.  Y.  that  he  was  enabled  to  improve  his  hearing  power,  so 
that  he  could  produce  in  his  left  ear  a  degree  of  hearing 
quite  sufficient  for  all  ordinary  purposes.  This  was  done  by 
the  introduction  "  of  a  spill  of  paper  previously  moistened 
with  cotton  to  the  bottom  of  the  passage. "t 

This  was  the  real  discovery  of  the  artificial  membrana  tym- 
pani,  although  Dr.  Martel  Frank,  in  his  cyclopaedic  text-book, 
refers  to  a  means  of  preventing  injury  to  the  ear,  but  not  of 
improving  the  hearing  when  the  membrana  tympani  is  lost, 
which  is  the  use  of  a  silver,  gold,  or  lead  tube,  the  inner  end 
of  which  is  covered  by  a  membrane.  The  fact  that  such  a 
means  of  protecting  the  ear  was  used  in  1640  has  been  already 
alluded  to.  It  cannot  be  said,  however,  to  be  an  artificial 
membrana  tympani  in  the  sense  of  Yearsley's  cotton  wool, 
which  he  soon  substituted  for  the  paper  of  the  New  York  pa- 
tient, or  of  Toynbee's  disk  of  rubber  attached  to  a  wire.  The 
artificial  membrana  t}rmpani  has  proved  itself  a  very  valuable 

*  Treatise  on  the  Structure,  Economy,  and  Diseases  of  the  Ear.    American 
edition,  1843. 

f  On  Deafness.    Tearsley,  p.  221. 


44  A  SKETCH   OF  THE 

means  of  treatment,  and  is  in  constant  use  by  many  of  those 
who  treat  suppurations  of  the  middle  ear.* 

Yearsley's  book,  as  its  title  indicates,  "  Deafness  Prac- 
tically Illustrated,"  is  not  to  be  rated  with  the  text-books  of 
Wilde,  Toynbee,  Kramer,  or  Frank. 

The  work  of  Dr.  Frmik,\  already  alluded  to,  will  be  found 
a  valuable  work  of  reference,  although  it  lacks  individualit}7. 
Hoffman's  (Troltsch's)  mode  of  examining  the  auditory  canal 
and  membrana  tympani  is  fully  described  by  Frank  on  page 
49  of  his  book ;  but  he  attached  no  importance  to  it,  not  fore- 
seeing that  it  was  to  supersede  all  other  methods,  as  it  has 
done,  as   improved  and  brought  into  general  iise   by  Yon 

Troltsch. 
1843]  The  work  of  William  B.  WiMe,\  surgeon  to  St.  Mark's 
Hospital,  which  was  republished  in  this  country,  where 
it  has  had  a  large  circulation,  and  which  was  translated  into 
German,  probably  did  more  to  place  our  science  upon  a 
sound  basis  than  anything  that  has  been  done  in  otology  since 
the  days  of  Valsalva.  This  work  was  founded  on  the  obser- 
vations of  a  careful  observer,  who  had  acquired  fine  habits  of 
study  as  a  skillful  ophthalmologist.  It  was  not,  as  the  works 
of  Lincke  and  Frank,  a  cyclopaedia  of  what  had  been  written 
on  otology,  nor  was  it  full  of  absurd  theories  like  that  of  Kra- 
mer, but  it  consisted  in  the  application  of  thorough  anatomi- 
cal, physiological,  and  therapeutical  knowledge  to  the  study 
of  an  organ  that  had  been  hitherto  treated  as  if  it  were  sui 
generis,  and  not  subject  to  the  same  accidents  and  diseases, 
and  consequences  of  those  diseases,  as  other  parts  made  up, 
in  like  manner,  of  integument,  of  cartilage,  mucous  mem- 
brane, periosteum,  and  bone.  In  fact,  Wilde — now  Sir  Wil- 
liam Wilde,  in  consequence  of  the  well-earned  recognition  of 
his  Queen — brought  otology,  or  aural  surgery  as  he  called 
this  department,  down  from  the  terra  incognita  of  the  ancients 
to  a  point  where  it  could  be  investigated  by  the  average 
practitioner,  and  where  it  was  respected  by  all.     He  gave  us 

*  Frank,  p.  293. 

f  Practiscke  Anleitung  zur  Erkenntniss  und  Bekandlung  der  Ohrenkrank- 
}>eiten.     Erlanger,  1845. 

X  Practical  Observations  on  Aural  Surgery.     London. 


PEOGEESS   OF  OTOLOGY.  45 

the  conical  specula,  reviving  a  suggestion  of  Dr.  Newburg  of 
Brussels  and  Ignaz  Gruber  of  Vienna,  and  drove  the  unhandy 
ones  of  Fabricius  and  Kramer  out  of  use.  More  than  all,  he 
taught  us  that  the  most  of  aural  disease  was  dependent  upon 
inflammation,  and  not  upon  that  which  was  one  of  Kramer's 
pet  ideas  at  that  time,  "nervous  disease,"  whatever  that  may 

mean. 
186D]  Then  came  Toynbee's  book,*  which  is  mainly  valua- 
ble for  its  anatomical  and  pathological  investigations.  It 
can  never  take  rank  with  Wilde's  book  as  a  useful  treatise  for 
the  practitioner,  indispensable  as  were  Toynbee's  labors  as  an 
anatomist  and  pathologist.     Mr.  James  Hinton's  supplement 

has,  however,  materially  improved  Toynbee's  treatise. 
1861]  Dr.  Anton  von  Troltsch,  of  Wurzburg,  published  a 
monograph  f  upon  the  anatomy  of  the  ear,  in  1861,  which 
he  entitled  a  contribution  to  the  scientific  establishment  of  otol- 
ogy. It  was  certainly  all  that,  and  something  more.  "While 
it  gave  a  very  simple  and  complete  account  of  the  anatomy, 
except  that  of  the  internal  ear,  there  were  many  wise  sugges- 
tions in  the  text  with  regard  to  the  treatment  of  aural  disease. 
Yon  Troltsch  showed  himself  to  be  what  in  the  eyes  of  Kra- 
mer is  a  reproach,  but  what  is,  in  those  of  the  profession  at 
large,  an  honorable  position,  a  disciple  of  Wilde  and  Toynbee. 
He  built  upon  the  foundations  which  the  clinical  skill  of  the 
Irish,  and  the  industrious  labors  of  the  English  observer  had 
made,  and  brought  otology  in  Germany  into  a  position  which 
made  it  an  inviting  department  of  labor.  His  work  upon  the 
anatomy  contains  the  results  of  many  original  investigations, 
which  will  be  found  in  the  anatomical  descriptions  of  this 

volume. 
1862]  This  work  on  the  anatomy  of  the  ear  was  soon  fol- 
lowed by  a  text-book  upon  its  diseases,  J  which  had  the 
same  scientific  characteristics  with  the  monograph  upon  the 
anatomy.  It  has  been  translated  into  the  English,  French, 
and  Italian  languages.     In  this  country  it  met  with  great 

*  The   Diseases   of  the  Ear :    their  Nature,   Diagnosis,   and   Treatment. 
Reprint,  Philadelphia. 

f  Die  Anatomie  des  Ohres.     Wurzburg,  1861. 
\  Die  Krankheiten  des  Ohres. 


46  A  SKETCH  OF  THE 

favor,  having  passed  through  two  editions,  and  it  has   given 
tone  to  all  the  otological  literature  and  investigations  of  its  day. 

Yon  Troltsch  improved  and  brought  into  general  use  the 
method  of  illumination  first  proposed  by  Dr.  Hoffman,  of 
Westphalia,  and  thus  at  one  step  advanced  the  science  very 
materially. 

In  1862,  the  same  year  that  Yon  Troltsch  issued  his  text- 
book, Dr.  Adam  Politzer,  of  Yienna,  promulgated  his  method 
of  injecting  the  middle  ear  with  air,  or  of  inflating  the  middle 
ear.  It  is  hard  to  overestimate  the  value  of  this  simple  pro- 
cedure, and  the  benefit  to  our  science  and  art  that  its  invention 
caused. 

The  writer  can  but  quote  the  opinion  of  an  eminent  prac- 
titioner of  this  city,  who  in  speaking  of  Politzer's  method  once 
said  to  him  :  "  If  a  man  were  to  take  this  air-bag,  and  travel 
through  the  country,  advertising  himself  as  an  aurist,  and 
blow  up  all  the  ears  indiscriminately  that  were  brought  to 
him,  he  would  be  a  very  successful  quack."  Indeed,  the 
effects  of  this  means  of  treatment,  especially  in  the  case  of 
children,  or  adults  who  have  suffered  but  a  short  time  from 
impairment  of  the  hearing,  from  disease  of  the  middle  ear,  are 

often  wonderful. 
1863]        Dr.  Julius  Erliard  published  a  work  upon  the  dis- 
eases of  the  ear,  which  is  a  peculiar  mixture  of  truth 
with  error.     The  book  is  rather  curious  and  interesting.* 

In  1864,  Dr.  von  Troltsch,  Dr.  Politzer,  and  Dr.  Herman 
Scliwartze,  of  Halle,  issued  the  first  number  of  the  Archiv  fur 
Ohrenheilkunde,  a  work  which  has  been  regularly  continued 
under  their  management,  and  which  has  formed  a  true  guide 
to  the  otological  student  and  practitioner. 

In  1865  Dr.,  now  Professor,  Politzer  published  a  mono- 
graph upon  the  membrana  tympani,  which  was  translated  into 
English,  and  published  in  the  United  States,  by  my  friends 
and  colleagues  Drs.  Arthur  Mathewson  and  Homer  P.  New- 
ton, of  Brooklyn.  The  frequent  use  which  every  recent 
writer  on  otology  is  obliged  to  make  of  this  valuable  mono- 
graph, is  sufficient  evidence  of  its  merit. 

In  October,  1867,  the  first  number  of  the  Monatsschrift  fur 
*  Klinische  Otiatrie.    Berlin. 


PROGRESS   OF  OTOLOGY.  47 

Ohrenheilkunde  was  issued,  under  the  direction  of  Dr.  Volto- 
lini,  of  Breslau,  Dr.  Josef  Gruber,  of  Vienna,  Dr.  F.  E.  Weber, 
of  Berlin,  and  Dr.  N.  Riidinger,  of  Munich.  All  of  these  edi- 
tors have  contributed  very  much  to  the  scientific  advance  of 
otology ;  while  Dr.  Riidinger  has  probably  done  more  than 
any  anatomist  of  his  day  to  elucidate  the  anatomy  of  the 
Eustachian  tube.  His  photographic  atlas  of  the  ear  is  a  work 
of  permanent  value,  and  one  of  which  the  author  has  made 
frequent  use   in   illustrating  some   of  the   chapters  of  this 

work. 
1860]  Dr.  8.  Moos,*  of  Heidelberg,  issued  a  practical  treatise 
on  aural  disease  in  1866,  and  Dr.  Gruber, \  of  Vienna, 
one  in  1870.  Both  of  these  volumes  show  much  original  re- 
search and  are  worthy  of  an  English  translation,  which  would 
bring  them  before  a  much  larger  circle  of  readers. 

The  American  Otological  Society  was  established  in  1868, 
and  has  held  annual  meetings  since,  and  has  published  four 
volumes  of  Transactions.  To  these  papers  the  author  has 
had  frequent  occasion  to  refer  in  the  preparation  of  the  fol- 
lowing chapters,  and  it  is  believed  that  they  furnish  evidence 
of  the  high  character  of  the  work  that  has  been  done  by 
American  otologists. 

No  outline  of  what  has  been  done  in  the  last  twenty  years 
for  otology  would  be  complete  without  a  reference  to  the  writ- 
ings of  Professor  Edward  H.  Clarke,  of  Harvard  University. 
Dr.  Clarke  published  a  paper  on  perforations  of  the  membrana 
tympani,J  its  causes  and  treatment,  which  was  probably  the 
best  that  had  been  written  on  this  subject.  It  received  a  full 
recognition  among  foreign  authorities.  In  this  article  is  con- 
tained a  very  important  sentence,  quoted  by  Von  Troltsch  in 
his  text-book,  a  passage  full  of  meaning  and  warning  :  "  So 
necessary  is  a  careful  attention  to  the  ear,  during  the  course  of  an 
acute  exanthema,  that  every  physician  who  treats  such  a  case  ivith- 
out  careful  attention  to  the  organ  of  hearing,  must  be  denominated 
an  unscrupulous  practitioner" 

Dr.  Clarke  has  also  published  a  monograph  upon  polypus 

*  Klinik  der  Ohrenkrankheiten. 
f  Lehrbuck  der  Ohrenheilkunde. 
\  American  Journal  of  the  Medical  Sciences,  January,  1858. 


48  A   SKETCH   OF  THE 

of  the  ear,  which  contains  very  much  of  value  as  to  the 
nature  and  treatment  of  these  products  of  inflammation.* 

In  1869,  Drs.  H.  Kipajyp,  of  New  York,  and  8.  Moos,  of 
Heidelberg,  began  the  publication  of  the  Archives  of  Ophthal- 
mology and  Otology,  which  are  issued  simultaneously  in  Eng- 
lish and  German,  and  which  have  added  much  to  the  scienti- 
fic interest  in  otology.  The  union  of  the  two  branches  of  sci- 
ence in  so  valuable  a  journal  has  certainly  assisted  to  gain  the 
respect  of  the  profession  for  the  department  of  otology. 

Dr.  Laiorence  Tiirnbull  issued  a  treatise  on  the  ear  in  1872, 
which  more  than  any  other  book  as  yet  published  exhibits  the 
work  done  in  otology  on  this  side  of  the  Atlantic. 

Lincke,  writing  in  1840,  regrets  that  in  Germany  no  clinique 
for  the  treatment  of  aural  patients  had  as  yet  been  organized. 
Dr.  Reiner,  he  says,  had  attempted  to  do  so  in  Munich,  but 
had  failed,  as  had  Dr.  Lincke  in  Leipsic ;  and  we  know  that 
Saunders  and  Cooper  had  failed  in  establishing  one  in  Lon- 
don ;  for  in  1804,  Saunders  had  an  eye  and  ear  infirmary  in 
London,  under  the  name  of  the  "  New  London  Dispensary  for 
Curing  Diseases  of  the  Eye  and  Ear."  But  the  aural  part  was 
so  unsuccessful,  that  it  became  necessary  to  close  it  to  the  au- 
ral practice.  John  Harrison  Curtis,  in  1816,  was  more  suc- 
cessful, and  when  Lincke  wrote,  his  dispensary  was  still  carried 
on.  In  1828,  the  New  York  Eye  and  Ear  Infirmary,  which  had 
been  in  existence  eight  years,  treated  91  cases  of  diseases  of 
the  ear,  to  925  of  diseases  of  the  eye.  That  institution,  ac- 
cording to  its  last  published  report,  treated  more  than  2,000 
aural  cases,  while  every  large  city  of  Europe  and  America  now 
enjoys  the  benefits  of  institutions  where  aural  diseases  are 
properly  and  specially  treated. 

The  striking  want  of  success  in  the  treatment  of  aural  dis- 
ease was  due  to  the  fact,  that  as  yet  no  simple  means  had 
been  found  for  examining  the  membrana  tympani  and  audi- 
tory canal.  Besides  this,  the  pharynx  was  not  recognized  as 
the  point  of  origin  of  the  most  of  aural  diseases,  and  there 
was  not  a  simple  means  of  opening  and  treating  the  Eusta- 
chian tube.    All  these  difficulties  have  been  removed  in  the 

*  Observations  on  the  Nature  and  Treatment  of  Polypus  of  the  Ear.    Bos- 
ton, 1867. 


AUTHORITIES.  49 

nineteenth  century,  and  in  many  details  of  treatment  great  ad- 
vances have  been  made,  which  render  the  care  of  aural  disease 
quite  as  satisfactory  as  that  of  any  other  of  human  ills.  This 
is  not  altogether  due  to  the  fact  that  so  many  new  truths  have 
been  discovered,  but  much  of  the  gratifying  change  has  re- 
sulted from  the  sweeping  away  of  the  webs  of  error. 

In  concluding  this  introductory  chapter,  the  author  begs 
that  the  reader  will  bear  in  mind,  that  he  has  not  attempted  to 
make  it  more  than  an  outline  of  what  has  been  done  in  otology 
from  the  earliest  times  until  our  own  day.  I  have  attempted 
to  sketch  only  that  which  has  left  its  traces  upon  the  science, 
and  which  has  contributed  materially  to  its  progress.  I 
have  merely  desired  to  give  such  a  historical  account  of  the 
work  of  the  Fathers  as  would  render  any  frequent  references 
to  them  unnecessary  in  the  body  of  this  work,  and  one  which 
may  be  a  guide  and  encouragement  for  the  workers  of  the 
present  and  the  future.  The  results  of  the  investigations  of 
a  more  recent  period  will  be  found,  as  far  as  they  pertain  to 
the  subjects  treated  in  this  volume,  in  the  appropriate  chapters. 


AUTHORITIES 
CONSULTED   IN   PREPARING   THE   PRECEDING   HISTORICAL   SKETCH. 

Arcfiiv  fur  Ohrenheilkunde.  Herausgegeben  von  A.  Von  Troltsch,  A.  Polit- 
zer,  und  H.  Schwartze.     Wtirzburg.     Bd.  1 — 6. 

Archives  of  Ophthalmology  and  Otology.  Edited  and  published  simultane- 
ously in  English  and  German,  by  Prof.  H.  Knapp,  M.D.,  in  New  York, 
and  Prof.  S.  Moos,  M.D.,  in  Heidelberg.  Volumes  I.  to  III.  New  York  : 
William  Wood  &  Co.  Carlsruhe :  Chr.  F.  R.  Miillersche  Hof-Buch- 
handlung,  1869-1872. 

Allen,  Peter.     Lectures  on  Aural  Catarrh.     J.  &  A.  Churchill.     London,  1871. 
!Beck,  Karl  Joseph.     Die  Krankheiten  des  Gehoerorganes.     Heidelberg  und 
Leipzig,  1827. 

Note. — For  the  convenience  of  the  reader  who  may  desire  to  consult  the  original 
authorities,  which  the  author  has  examined  in  preparing  the  preceding  sketch,  their  com- 
plete titles  are  here  given.  The  bihliography  will,  however,  he  seen  to  refer  only  to  the 
works  actually  examined,  and  not  to  those  mentioned  as  quoted  by  the  authorities. 

4 


50  AUTHORITIES. 

2?iograp7iie  Medicale.     Tom.  I.-VII.     Paris :  C.  L.  F.  Panckoucke. 
Clarke,  Edward  H.     American  Journal  of  the  Medical  Sciences,  Jan.,  1858. 
Clarke,  Edward  H.     Observations  on  the  Nature  and  Treatment  of  Polypus 
of  the  Ear.     Boston,  1867. 

Curtis,  John  Harrison.  A  Treatise  on  the  Physiology  and  Diseases  of  the 
Ear.     Third  edition.     London  and  Edinburgh,  1823. 

Cyclopaedia  of  Anatomy  and  Physiology.    London,  1839.     Longman,  Brown, 

Green  &  Longmans.     Article,  "  The  Organ  of  Hearing." 
Dunglison,  Robley.     History  of  Medicine,  from   the  earliest  ages  to  the 

commencement  of  the  nineteenth  century.     Philadelphia :  Lindsay  and 

Blakiston,  1872. 
HJncyclopatdia ,  Chambers'.    J.  B.  Lippincott  &  Co.    Philadelphia,  1872. 
Utrhard,  Julius.     Klinische  Otiatrie.     A.  Hirschwald.    Berlin,  1863. 
Fabricitis  of  Acquapendente.     Opera  Omnia  Anatomica  et   Physiologica. 

Lugduni  Batavorum,  1738. 
J^ranfc,  Martell.     Practische  Einleitung  der  Erkentniss  und  Behandlung  der 

Ohrenkrankheiten.     Erlangen,  1845. 
G?°uber,  Josef.     Lehrbuch  der  Ohrenheilkuude.     Wien,  1870. 
Henle,  J~.     Handbuch  der  Menschen.     Bd.  II.     Braunschweig,  1866. 
JZerodotus.     A  new  and  literal  version  from  the  text  of  Baehr.     By  Henry 

Cary,  M.A.     London  :  Henry  G.  Bohn,  1854. 
Hard,  J~.  Jl€.  G.     Die  Krankheiten  des  Ohres  und  des  Gehors.     Aus  dem 

Fransosichen.     Weimar,  1822. 
Jones,  T.  Wharton.     The  Organ  of  Hearing,  in  Cyclopaedia  of  Anatomy  and 

Physiology.     London,  1839,  vol.  ii. 
JLinctce,  Carl  Gustav.     Handbuch  der  Theoretischen  und  Praktischen  Ohren- 

heilkunde.     Bd.  I.,  II.     Leipzig,  1837-1840. 
JL/'amer,  IV    Die  Ohrenheilkuude  der  Gegenwart  (1860.)    Berlin,  1861. 
A'ramer,  If.     The  Aural  Surgery  of  the  Present  Day.    Translated  by  Henry 

Power.     New  Sydenham  Society.     London,  1863. 
Iframe?*,  IV.     Handbuch  der  Ohrenheilkunde.     Berlin,  1867. 
JLYamer,  JV      Ohrenkrankheiten   und   Ohrenaerzte   in    Deutschland    und 

England.     Ein  Nachtrag  zur  Ohrenheilkunde  der  Gegenwart.     Berlin, 

1865. 
Jframer,  7V.    Die  "  exakten  "  deutschen  Ohrenarzte.     Berlin,  1871. 

Jlfonatsschrift  fur  Ohrenheilkunde.     Bd.  I.,  vi. 

Jfonro,  Alexander.  Three  Treatises  on  the  Brain,  tie  Eye,  and  the  Ear. 
Edinburgh,  1797. 

Mbos,  S.     Klinik  der  Ohrenkrankheiten.     Wien  :  W.  Braumiiller,  1866. 

'Politzer,  Adam.  Die  Beleuchtungsbilder  des  Trommelfells  in  Gesunden 
und  Kranken  Zustande.     Wien,  1865.     Willi  elm  Braumiiller. 

'Politzer,  Adam.  The  Membrana  Tympani  in  Health  and  Disease,  &c. 
With  Supplement.  Translated  by  A.  Matthewson,  M.D.,  and  H.  G.  New- 
ton, M.D.     New  York:  William' Wood  &  Co.,  1869. 


AUTHORITIES.  51 

Saissy,  J~.  j±.,  JIT.T>.  An  Essay  on  the  Diseases  of  the  Internal  Ear. 
Translated  from  the  French  by  Nathan  R.  Smith,  M.D.  With  a  Supple- 
ment on  Diseases  of  the  External  Ear  by  the  Translator.  Baltimore, 
1829. 

Saunders,  John  Cunningham.  The  Anatomy  of  the  Human  Ear,  illustrated 
by  a  series  of  Engravings  of  the  natural  size,  with  a  treatise  on  the  Dis- 
eases of  that  Organ,  the  causes  of  deafness  and  their  proper  treatment. 
First  American,  from  the  second  London  edition.  With  notes  and  addi- 
tions by  Wm.  Price,  M.D.     Philadelphia  :  Benjamin  Warner,  1821. 

Schwartze,  JET.  Die  Wissenschaftliche  Entwicklung  der  Ohrenheilkunde, 
Archiv  fur  Ohrenheilkunde,  Bd.  I. 

Shrapnellj  Henry  Jones.  On  the  Form  and  Structure  of  the  Membrana 
Tympani,  p.  120 ;  on  the  Function  of  the  Membrana  Tympani,  p.  282 ; 
on  the  Nerves  of  the  Ear,  p.  505 ;  the  London  Medical  Gazette,  vol.  x. 
April  7, 1832,  to  September  29, 1832.    London,  1832. 

Soemmering,  Sam.  Thorn.  Icones  organi-auditus-humani.  Frankfort  a.  M., 
1806. 

Strieker,  S.  Handbuch  der  Lehre  den  Geweben,  des  Menschen  und  des 
Thieres.    Leipzig,  1869-1871. 

St7°icker,  S.  A  Manual  of  Histology.  Translated  by  Henry  Power  and 
others.  American  translation.  Edited  by  Albert  H.  Buck.  New  York, 
1872. 

Transactions,  Philosophical,  of  the  Royal  Society  of  London.  For  the 
years  1800,  1801. 

Transactions  of  the  American  Otological  Society.    New  York.  Vol.    I.— III. 

Toynbee,  Joseph.  A  Descriptive  Catalogue  of  Preparations  illustrative  of 
the  Diseases  of  the  Ear,  in  the  Museum  of  Joseph  Toynbee,  F.R.S. 
London,  1857. 

Toynbee,  Joseph.  The  Diseases  of  the  Ear,  their  Nature,  Diagnosis,  and 
Treatment.     (Reprint.)    Philadelphia,  1860. 

Toynbee,  Joseph.  The  Same,  with  a  Supplement  by  James  Hinton.  Lon- 
don, 1871. 

Tumbitll,  Lawrence.  A  Clinical  Manual  of  the  Diseases  of  the  Ear. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1872. 

Yon  Troltsch,  Anton.  Die  Anatomie  des  Ohres,  in  ihrer  Anwendung  auf 
dem  Praxis.     Wiirzburg,  1861. 

yon  Troltsch,  Anton.    Die  Krankheiten  des  Ohres.    Ihre  Erkentniss  und 
Behandlung.     Wiirzburg,  1862. 
The  same,  4  Aufgabe. 

Yon  Troltsc7i,  Anton.  The  Diseases  of  the  Ear,  their  Diagnosis  and  Treat- 
ment. Translated  into  English  by  D.  B.  St.  John  Roosa,  M.D.  New 
York  :  William  Wood  &  Co.,  1864. 

Yon  Troltsch,  Anton.  Treatise  on  the  Diseases  of  the  Ear,  including  the 
Anatomy  of  the  Organ.  Second  edition,  from  the  fourth  German.  Trans- 
lated and  edited  by  D.  B.  St.  John  Roosa,  M.D.  New  York  :  William 
Wood  &  Co.,  1869. 


553  AUTHOKITIES. 

yfilde,  William  K.      Some  Observations  on  the  Early  History  of  Aural 

Surgery,  and  the  Nosological  Arrangement  of  Diseases  of  the  Ear,  by  W. 

E.  Wilde,  M.R.I.A.    The  Dublin  Journal  of  Medical  Science.     Vol.  xxv. 

Dublin,  1844. 
Tfilde,  William  R.      Practical  Observations  on  Aural  Surgery,  and  the 

Nature  and  Treatment  of  Diseases  of  the  Ear,  by  William  R.  Wilde. 

London :  John  Churchill,  1853. 

ITearsley,  James.  Deafness  Practically  Illustrated.  Being  an  Exposition 
of  the  Nature,  Causes,  and  Treatment  of  Diseases  of  the  Ear.  Sixth  edi- 
tion.   London :  John  Churchill  &  Sons,  1863. 


CHAPTER  II. 

ANATOMY  OF  THE  AURICLE  AND  THE  EXTERNAL  AUDITORY 

CANAL. 

The  beautiful  appendage  to  the  organ  of  hearing,  which 
is  called  the  auricle,  or  little  ear,  has  as  its  functions  the  recep- 
tion, reflection,  and  condensation  of  the  waves  of  sound.  Its 
general  shape  is  that  of  a  funnel.  Its  framework,  or  basis,  is 
made  up  of  flexible  fibro-cartilage,  and  it  is  from  one  to  two 
millimetres  in  thickness.  The  cartilage  is  of  the  variety 
known  as  reticular,  and  it  is  covered  by  perichondrium  which 
contains  many  elastic  fibres.  These  fibres  pass  into  the  sub- 
stance of  the  cartilage,  and  form  a  network  in  the  meshes  of 

Fig.  1. 


1.  Helix.     2.  Anti-helix. 


TJie  Auricle. 

3.  Fossa  helicis.     4.  Concha. 
7.  Lobe. 


5.  Anti-tragus.     6.  Tragus. 


54 


ANATOMY   OF  THE  AUKICLE. 


which  small  cartilage  cells  are  embedded.  From  the  time  of 
Eufus  of  Ephesus  (see  page  19),  the  different  parts  of  the  auri- 
cle, which  give  it  its  beautiful  and  useful  shape,  have  been 
named  as  follows  : 


F.c. 


A.t. 


C.h. 


Profile  View  of  the  Skull,  with  the  Skeleton  or  Cartilage  of  the  Auricle,  as  well  as  that  of  the  Ex- 
ternal Auditory  Canal.     The  latter  is  exposed  and  drawn  downwards,  cm.    After  Henle. 

1.  Meatus  auditorius  extemus.  2.  Tuberculum  articulare  of  the  temporal  bone.  3.  Mastoid 
process.  +  Transverse  section  of  the  zygomatic  process.  H.  Helix.  A.  h.  Anti-helix. 
F.  t  Fossa  triangularis.  S.  Scapha,  or  Fossa  navicularis.  F.  c.  Concha.  C.  h.  Cauda 
helicis.  A.  t.  Anti-tragus.  T.  Tragus.  **  *.  Fissures  in  the  cartilage  of  the  external 
auditory  canal. 

The  edge  that  forms  the  outer  border  of  the  auricle  is 
called  the  helix,  from  a  Greek  word,  efai;,  anything  twisted, 
smoog),  to  turn  around..  This  ridge  varies  in  breadth,  and  is 
more  or  less  distinct  in  different  individuals,  according  to  the 
care  that  has  been  taken  to  preserve  the  shape  of  the  ear.  It 
begins  at  a  point  on  the  concave  surface  of  the  cartilage,  called 
the  spine  or  crest  of  the  helix,  spina  seu  crista  helicis.  By  fol- 
lowing down  the  posterior  border  with  the  finger,  it  will  be 
seen  that  its  tissue  does  not  pass  into  the  lobe  of  the  ear,  but 
that  the  latter  is  formed  by  the  integument  alone. 


ANATOMY  OP  THE  AUIIICLE.  55 

Just  beneath,  the  helix  is  a  fossa— -fossa  navicularis,  or 
boat-like  fossa — separating  it  from  a  second  ridge-like  bor- 
der, the  anti-helix.  Just  in  front  of  the  opening  into  the  audi- 
tory canal  the  cartilage  becomes  thickened,  and  forms  a  pro- 
jection or  edge  called  the  tragus,  or  goat,  because  hairs  usu- 
ally grow  upon  this  part,  which  were  supposed  by  the  ancients 
to  give  it  a  certain  kind  of  resemblance  to  the  beard  of  that 
animal.  Just  opposite  to  this,  across  the  mouth,  or  meatus,  of 
the  auditory  canal,  is  a  similar  projection  called  the  anti-tragus. 
The  greatest  concavity  of  the  auricle  is  called  the  concha,  from 
a  Greek  word  meaning  concave  shell.  This  concavity  passes 
into  the  meatus  auditorius  externus,  or  outer  opening  of  the  ear. 
Above  the  concha,  and  separated  from  it  by  a  projection,  is  a 
depression  of  a  triangular  shape,  fossa  triangularis. 

Elastic  fibrous  bands,  springing  from  the  malar  bone  and 
mastoid  process,  fasten  the  auricle  in  its  position,  and  allow  a 
certain  mobility  to  it!  The  auricle  is  completely  covered  by 
the  common  integument  of  the  body.  This  integument  is 
more  firmly  adherent  to  the  anterior  surface  of  the  cartilage 
than  to  the  posterior,  and  from  it,  at  the  extremity  of  the  ear, 
a  projection  of  tip,  called  the  lobe,  is  formed.  This  portion 
is  poorly  supplied  with  blood  and  nerves,  and  is  consequently 
not  very  sensitive.  It  is  also  very  distensible,  and  when  over- 
burdened by  heavy  ear-rings  may  become  very  much  elongated, 
and  thus  its  beauty  be  greatly  marred. 

In  rare  cases  the  cartilaginous  structure  extends  to  the  lobe,  when  severe 
reaction  will  follow  the  usually  harmless  operation  of  boring  the  ears  for  the 
insertion  of  ear-rings. — Gruber* 

MUSCLES    OF    THE    AURICLE. 

There  are  three  muscles  which  move  the  auricle,  and  which, 
are  attached  to  the  surrounding  parts.     They  are— 
I.  Levator  or  Attollens  aurem, 
II.  Attrahens  aurem, 
III.  Betrahens  aurem. 
They  are  placed  immediately  beneath  the  skin.     In  man 
they  are  usually  rudimentary  ;  but  they  are  the  analogues  to 

*  Lehrbuch,  p.  61. 


53  ANATOMY  OF  THE  AUEICLE. 

certain  large   and  important  muscles  in  some  of   the  mam- 
malia. 

Some  persons,  and  especially  those  whose  hearing  has  become  impaired 
from  chronic  aural  disease,  acquire  considerable  power  in  employing  these 
muscles,  as  well  as  the  intrinsic  ones.  I  have  often  observed  their  action  when 
patients  were  listening  for  the  ticking  of  a  watch,  which  was  being  gradually 
approached  to  the  ear,  and  it  may  be  observed  when  such  persons  are  attempt- 
ing to  hear  distant  sounds. 

The  levator  is  the  largest  of  the  three  muscles.  It  is  thin 
and  fan-shaped.  It  arises  from  the  aponeurosis  of  the  occipito- 
frontalis,  and  its  fibres  converge  to  be  inserted  into  the  upper 
part  of  the  auricle. 

The  attrahens  aurem  is  the  smallest  of  the  three.  It  arises 
from  the  lateral  edge  of  the  aponeurosis  of  the  occipito-fron- 
talis  muscle.  Its  fibres  converge  and  are  inserted  in  front  of 
the  helix.  This  muscle  is  separated  by  the  temporal  fascia 
from  the  temporal  artery  and  vein. 

The  ret) -aliens  aurem  consists  of  two  or  three  bundles  of 
fibres,  which  arise  from  the  mastoid  process.  They  are  in- 
serted into  the  lower  part  of  the  cranial  surface  of  the  concha. 

The  names  of  these  muscles  indicate  their  action  :  the 
levator  slightly  lifts  the  auricle,  the  attrahens  draws  it  forwards 
and  upwards,  and  the  retrahens  draws  it  backward. 

Hyrtl  states  that  no  animal  has  a  lobe  as  a  part  of  the  auricle,  and  that 
none  of  the  mammals  living  in  water  have  this  appendage.* 

INTRINSIC    MUSCLES. 

The  auricle  has  also  a  set  of  muscles  which  are  contained 
in  its  structure  ;  intrinsic  muscles,  as  they  are  called  by  several 
authors.  With  a  single  exception  these  muscles  run  between 
different  parts  of  the  cartilage  of  the  auricle  and  of  the  audi- 
tory canal. 

They  are  all  muscles  of  animal  life,  but  they  are  very 
slightly  developed,  and  are  therefore  pale,  and  thin,  and  flat. 
They  lie  closely  upon  the  cartilage,  and  are  inserted  into  its 
fibrous  covering  by  means  of  short  tendinous  fibres. 

They  are  sometimes  absent.     It  is  possible,  although  not 

*  Lehrbuch  der  Anatomie  des  Menschen,  Bd.  II,  p.  517. 


ANATOMY  OF   THE  AURICLE. 


57 


certain,  that  they  always  exist  at  birth,  but  that  they  subse- 
quently atrophy  from  want  of  use. 

Two  of  these  intrinsic  muscles  of  the  auricle  belong  to  the 
cartilage  of  the  auditory  canal,  the  remainder  to  the  auricle. 
The  former  occasionally  run  over  into  the  latter. 

1.  Traglciis, — This  muscle  lies  on  the  anterior  surface  of 
the  anterior  wall  of  the  cartilage  of  the  auditory  canal,  near 

Fig.  3. 


M  5 

Muscles  of  the  External  Ear.    After  Henle. 

M.  Meatus  auditorius  externus.    H".  Spine  of  the  helix.    1.  Attollens,  or  Levator  aurem.    2. 
Helicis  major.    3.  Eelicis  minor.    4.  Tragicus.    5.  Anti-tragicus. 


the  upper  and  the  lateral  border.  It  is  quadrangular  in  shape, 
and  nearly  as  long  as  it  is  broad.  It  is  composed  of  parallel 
fibres  running  nearly  in  a  vertical  direction.  (See  Fig.  3,  4.) 
2.  Anti-tragicus. — This  muscle  lies  on  the  posterior  surface 
of  the  posterior  wall  of  the  cartilage  of  the  meatus.  (See 
Fig.  3.) 


58 


ANATOMY   OF  THE  AUBICLE. 


3.  Hclicis  Minor.  Henle  says  tliat  this  is  the  most  con- 
stant of  the  muscles  of  the  auricle,  and  that  it  is  often  the 
strongest  of  the  intrinsic  muscles.  It  is  a  fan-shaped  muscle, 
and  is  found  on  the  lateral  surface  of  the  helix  between  its 
root  and  spine.     (Fig.  3,  3.) 

4.  Helicis  Major. — This  muscle  runs  over  the  anterior  mar- 
gin of  the  helix,  and  is  only  loosely  connected  with  it,  and 
passes  over  into  a  kind  of  tendinous  termination  into  the 
levator  of  the  auricle.     (Fig.  3,  2.) 

5.  Transversa  Auricula?. — Transverse  Muscle  of  the  Auricle. 
— This  muscle  consists  of  fibres  which  are  not  very  thickly 
combined  with  loose  connective  tissue  fibres,  that  run  on  the 

Fig.  4. 


Om 


Ec- 


Cm- 


View  of  the  Cartilage  and  Muscles  on  the  Posterior  Surface  of  the  Auricle.    After  Henle. 

E.  t.  Elevation  made  by  fossa  mangularis.  E.  c.  Elevation  formed  by  concha.  O.  m.  Oblique 
muscle.  E.  s.  Elevation  of  scaphoid  fossa.  T.  a.  Transversus  auricula.  C.  m.  Carti- 
lage of  the  external  auditory  Canal.  *.  Attachment  to  the  edge  of  the  osseous  canal. 
C.  c.  Cartilage  of  the  auricle.    C.  h.  Cauda  helicis. 

posterior  surface  of  the  auricle  from  the  scaphoid  fossa  to  the 
concha  over  the  deep  furrow  corresponding  to  the  anti-helix. 
(Fig.  4) 


ANATOMY  OF  THE  AUEICLE.  59 

6.  Oblique  Muscle  of  the  kuriclv. —Obliquus  Auriculas. — This 
muscle  bridges  over  the  furrow  on  the  posterior  surface  of 
the  auricle,  which  corresponds  to  the  prominence  on  the  sur- 
face of  the  cartilage  that  forms  the  lower,  sharp  root  of  the 
anti-helix.     (See  Fig.  4.) 

7.  Dilator  of  the  Concha.  (Masculus  incisurce  majoris  auri- 
cula Santorini.)  Sometimes  the  above-named  muscle  is  found 
on  the  tragus. 

Hyrtl*  has  found  it  arising  from  the  anterior  circumference 
of  the  external  meatus,  whence  it  runs  downwards  and  out- 
wards to  the  lower  border  of  the  tragus,  which  it  draws  for- 
ward, and  thus  enlarges  the  space  of  the  concha. 

The  same  author  says  that  he  knows  of  no  instance  of  the 
voluntary  change  in  form  of  the  auricle  by  the  action  of  this 
muscle. 

"  The  power  of  moving  the  auricle  as  a  whole,  is,  however,  by  no  means 
very  rare.  Holler  speaks  of  many  such  cases,  and  B.  8.  Albin,  the  greatest 
anatomist  of  the  eighteenth  century,  used  to  take  off  his  wig  at  his  lectures,  to 
show  his  students  how  easily  he  could  move  the  muscles  of  the  auricle." 

Duchenne  and  Ziemssen,f  by  means  of  faradization,  found  that  the  muscles 
of  the  cartilage  of  the  meatus  narrowed  the  incisura  auris,  and  thus  the  canal 
leading  into  the  ear,  preventing  a  portion  of  the  sound  undulations  from  reach- 
ing the  memhrana  tympani,  while,  according  to  Duchenne,  the  helicis  major 
and  minor  lift  up  the  helix,  and  thus  favor  the  access  of  the  sound  waves. 


BLOOD-VESSELS  OP  THE  AURICLE. 
Arteries : 

1.  Posterior  auricular,  from  the  external  carotid. 

2.  Anterior  auricular,  from  tbe  temporal. 

(The  temporal  is  the  smaller  of  the  two  terminal  branches 
of  the  carotid.) 

3.  An  auricular  branch  of  the  occipital. 

It  will  thus  be  seen  that  the  blood  supply  of  the  auricle  is  entirely  from  the 
external  carotid  artery. 

The  veins  of  the  external  ear  empty  in  part  into  the  tem- 
poral vein,  as  well  as  into  the  external  jugular,  or  into  the 
posterior  facial  vein. 

*  Hyrtl,  1.  c,  p.  518.  f  Henle,  1.  c,  p.  729. 


60 


ANATOMY  OF  THE  EXTERNAL  AUDITORY  CANAL. 


/        NERVES  OF  THE  AURICLE. 

The  nerves  are  the — 

1.  Auricularis  rnagnus,  from  the  cervical  plexus.  The  cer- 
vical plexus  is  formed  by  the  anterior  branches  of  the  four 
upper  cervical  nerves. 

2.  Posterior  auricular,  from  the  facial. 

3.  An  auricular  branch  of  the  pneumogastric. 

4.  An  auriculotemporal  branch  of  the  inferior  maxillary 
nerve. 

The  branches  of  the  cervical  plexus  are  on  the  posterior 
side  of  the  auricle. 

Fig.  5. 


2  9 

Horizontal  Section  of  the  Head,  through  the  External  Auditory  Canal.    After  Henle. 

1.  Cartilage  of  the  External  Auditory  Canal.  '*.  Fissure  in  the  cartilage.  2.  Cartilage  of  the 
Auricle.  3.  Tuberculum  articulare  of  the  lower  jaw.  4.  Fossa  mandibularis.  5.  Mem- 
brana  tympani.  6.  Cavity  of  the  tympanum.  7.  Vestibule.  8.  Transverse  sinus.  9. 
Mastoid  cells. 

External  Auditory  Canal.  (Meatus  Auditorius  Externus.) 
— The  canal  leading  from  the  auricle  to  the  membrana  tym- 
pani consists  of  two  portions,  an  outer  part,  which  is  formed 
of  cartilage,  and  an  inner,  which  is  of  bone. 

Its  external  opening,  which  is  formed  by  the  cartilaginous 


ANATOMY   OF  THE   EXTERNAL  AUDITOEY   CANAL. 


01 


portion,  corresponds  anteriorly  and  below  with  the  margin  of 
the  external  ear.  Behind,  it  is  demarcated  by  the  ridge  which 
connects  the  anterior  border  of  the  auricle  with  the  margin  of 
the  osseous  meatus ;  above,  it  is  bounded  by  the  root  of  the 
helix. 

Inasmuch  as  the  membrana  tympani  is  not  on  a  horizontal 
plane,  the  walls  of  the  canal  do  not  extend  equally  far  inward. 
The  anterior  and  inferior  wall  is  the  longest. 

It  thus  becomes  impossible  to  give  an  exact  measurement 
of  the  canal  which  can  be  applied  to  all  ears.  The  canal  is  also 
curved,  and  its  cartilaginous  portion  is  very  elastic. 


Fig.  6 


a     3 


if. 


CM- 


cc 


m.f 


f\    \ 


'  CM'' 

Section  through  the  External  Meatus  and  the  Ear  at  the  point  of  junction  of  the  Cartilage  of 
the  Auricle,  c  c,  with  that  of  the  Auditory  Canal.    After  Henle. 

A  small  portion  of  the  upper  ivall  of  the  latter  remains  as  a  narrow  band,  CM'.  CM".  Lower 
wall  of  the  cartilage  of  the  external  meatus.  H7'.  Spine  of  the  helix.  L.  Lobe  of  the  ear. 
*.  Fibrous  lip  of  the  border  of  the  osseous  meatus.  1.  Epicranius  temporalis  muscle.  2. 
Levator  auricularis.  3.  Temporal  muscle.  4.  Upper  wall  of  the  osseous  canal.  5.  Cav- 
ity of  the  tympanum.  6.  Membrana  tympani.  7.  Stapes  bone.  8.  Vestibule.  9.  Mea- 
tus auditorius  internus  and  acoustic  nerve.  10.  Lower  wall  of  the  osseous  meatus.  11. 
Parotid  gland. 


The  first  curvature  is  described  by  Henle  as  zigzag  in 


62       ANATOMY  OF  THE  EXTEKNAL  AUDITOEY  CANAL. 

shape,  and  is  well  shown  in  the  two  preceding  cuts.  This  cur- 
vature is  constant. 

These  curvatures  may  be  overcome,  and  the  outer  portion 
of  the  canal  rendered  nearly  if  not  quite  straight,  by  drawing 
the  auricle  upwards  and  backwards. 

The  cartilaginous  portion  of  the  canal  is  interrupted,  espe- 
cially on  its  inferior  wall,  by  gaps  and  fissures — the  so-called 
Incisures  Santorini.  These  gaps  are  filled  up  by  fibrous  tissue. 
The  osseous  portion  is  an  integral  portion  of  the  temporal 
bone,  and  has  a  groove  for  the  insertion  of  the  membrana 
tympani.     (Sulcus  pro  membrana  tympani. — Hyrtl.) 

The  length  of  the  canal,  according  to  Hyrtl,  varies  from 
9  lines  to  one  inch.  The  average  length  of  the  canal,  accord- 
ing to  Von  Troltsch*  is  about  24  millimetres.  The  cartilagi- 
nous portion  forms  about  one-third  of  this,  or  8mm.,  and  the 
osseous  canal  the  remaining  two-thirds,  or  16mm. 

The  angle  which  the  upper  wall  of  the  canal  forms  with 
the  membrana  tympani,  is  an  obtuse  one ;  but  that  between 
the  lower  wall  and  the  drum-head  is  acute ;  it  is  one  of  about 
45°. 

The  width  of  the  canal  varies  as  well  as  the  length.  It  is 
widest  at  the  junction  of  the  osseous  with  the  cartilaginous 
canal,  and  next  to  the  membrana  tympani. 

According  to  Hyrtl,  if  the  canal  be  filled  with  wax,  the  cast 
is  that  of  a  spiral  turning  anteriorly,  inwards  and  downwards. 

The  auditory  canal  is  lined  by  integument,  and  not  by 
mucous  membrane.  Hence  it  is  not  correct  to  speak  of  a 
catarrh  of  the  external  auditory  canal.  This  integument  is 
merely  a  continuation  of  that  of  the  general  surface  of  the 
body.  The  nearer  it  approaches  the  membrana  tympani,  the 
thinner  it  becomes,  and  finally  it  covers  the  drum-head  as  a 
very  thin  layer. 

"  The  integument  of  the  cartilaginous  portion  of  the  canal 
is  1^-mm.  thick,  and  contains  soft  hairs,  with  their  sebaceous 
glands,  the  ceruminous  glands,  and  a  little  fat  in  its  subcuta- 
neous tissue.  In  the  osseous  part  of  the  canal,  the  integu- 
ment is  only  0.1mm.  in  thickness,  the  soft  hairs  become  very 

*  Treatise  on  the  Ear,  2d  American  Edition,  p.  18. 


ANATOMY   OP  THE   EXTEENAL  AUDITORY  CANAL.  63 

few,  and  the  ceruniinous  glands  are  found  only  on  the  poste- 
rior upper  wall,  where  they  are  generally  seen,  even  close  to 
the  membrana  tympani.  Small  papillae  are  found  arranged  in 
rows  under  the  cuticle,  and  also  a  corium  with  abundant  elastic 
fibres,  of  which  the  lower  layers  pass  into  the  periosteum."  * 

The  ceruminous  glands  are  like  the  sebaceous  or  sweat 
glands  in  their  development  and  secretion.  The  only  differ- 
ence between  the  secretion  of  the  two  kinds  of  glands,  is  that 
the  ceruminous  glands  contain  some  coloring  matter.  {Ceru- 
men is  probably  derived  from  cera  aurium. — Hyrtl.) 

The  substance  of  the  ceruminous  glands  is  a  yellowish 
white, .  rather  fluid  material,  which  consists  essentially  of  fat 
globules,  coloring  matter  and  cells  in  which  single  globules  of 
fat  and  coloring  matter  are  embedded  ;  there  are  also  hairs 
and  scales  of  epidermis  from  the  lining  of  the  meatus. — (Kessel.) 
When  the  cerumen  has  remained  in  the  canal  for  a  long  time, 
its  watery  contents  are  lost  by  evaporation,  and  it  becomes  a 
hard  mass. 

Sometimes  the  hairs  of  the  canal  grow  to  such  a  length  as 
to  obscure  the  view  of  the  meatus  and  the  drum-head.  In 
such  cases  I  have  been  obliged  to  remove  them  with  a  pair  of 
curved  scissors.  They  may  also  drop  off,  and,  lodging  on  the 
membrana  tympani,  become  a  source  of  annoyance,  by  causing 
a  tickling  sensation  in  the  ear.  Dr.  E.  F.  Weir  relates  such  a 
case.f 

According  to  Buchanan,  an  author  who  laid  too  much  stress 
upon  the  part  which  the  ceramen  plays  in  the  economy,  there 
are  from  one  thousand  to  two  thousand  ceruminous  glands. 

The  child  at  birth,  and  for  some  time  after,  has  no  osseous 
meatus.  The  cartilaginous  portion  is  at  first  attached  to  a 
membranous  part,  just  as  it  is  afterwards  to  the  osseous 
portion. 

Gruber  %  thinks  that  there  is  a  very  narrow  rim  of  osseous  canal  in  the  last 
months  of  embryonal  life. 

In  the  newly-born  this   membranous   portion  constitutes 

*  The  Organ  of  Hearing.  J.  Kessel,  Strieker's  Manual,  p.  951.  Translated 
by  J.  Orne  Green. 

f  Transactions  American  Otological  Society,  3d  year. 
%   Monatsschrift  filr  Ohrenheilkunde,  Bd.  II.,  p.  67. 


64:  ANATOMY  OF  THE  EXTERNAL  AUDITORY   CANAL. 

about  one-half  of  the  canal ;  but  it  gradually  becomes  shorter 
as  the  bone  grows  outwardly.* 

This  ossification  proceeds  irregularly,  and  often  leaves  a 
foramen,  which,  according  to  Yon  Troltsch,  has  been  mistaken 
for  a  pathological  condition,  the  result  of  caries. 

An  inflammation  of  the  meatus  in  a  young  child,  as  shown 
by  the  same  author,  might  readily  pass  through  this  foramen 
to  the  maxillary  articulation  or  parotid  gland. 

The  auditory  canal  of  the  dog  and  cat  are  closed  at  birth, 
as  are  their  eyelids.  There  is,  perhaps,  as  Yon  Troltsch  sug- 
gests, an  analogous  condition  in  the  closure  of  the  meatus  of 
young  children  with  vernix  caseosa,  and  the  approximation  of 
the  walls  of  the  meatus,  near  the  membrana  tympani. 

Some  birds  have  the  power  of  stopping  their  ears  by  a  kind  of  valve.  The 
turkey  has  a  kind  of  erectile  tissue  projecting  into  the  meatus,  so  that  it  can 
close  the  ears  more  or  less  perfectly  when  angry. — ( Yon  Troltsch) 

RELATIONS  OP  THE  AUDITORY  CANAL. 

The  cartilaginous  portion  is  bounded  anteriorly  and  inferi- 
orly  by  the  parotid  gland.  Cases  have  been  observed  where 
abscesses  of  the  parotid  have  discharged  into  the  auditory 
canal,  through  the  fissures  of  Santorini. 

Enlargements  of  the  parotid  or  lymphatic  glands  may  con- 
tract the  caliber  of  the  canal  by  pressure. 

The  anterior  wall  is  also  in  relation  with  the  posterior  wall 
of  the  articular  fossa  of  the  inferior  maxillary  bone.  Heuce  a 
blow  upon  the  chin  may  produce  a  fracture  of  this  plate,  and 
cause  a  hemorrhage  from  the  ear.  The  thick  articular  car- 
tilage protects  the  auditory  canal  and  temporal  bone  from  the 
full  force  of  such  a  blow. 

The  posterior  wall  is  made  up  by  the  mastoid  process  in 
such  a  way  that  the  canal  is  only  separated  from  the  trans- 
verse sinus  by  two  thin  plates  of  osseous  tissue  and  the  air- 
cells  lying  between  them.  The  superior  wall  is  covered  on  its 
upper  surface  by  the  dura  mater,  and  forms  a  portion  of  the 
floor  of  the  middle  fossa  of  the  skull. — (  Von  Troltsch.) 

The  wall  between  the  integument  of  the  canal,  as  is  shown 

*  Von  Troltsch,  1.  c,  p.  6. 


ANATOMY   OF  THE  EXTERNAL  AUDITORY  CANAL. 


65 


by  the  instructive  section  that  is  given  below,  may  be  exceed- 
ingly thin,  and  inflammations  of  the  meatus  may  produce  dis- 
ease of  the  brain. 

The  auditory  canal  is  bounded  above  and  behind  by  por- 
tions of  the  mastoid  cells,  that  are  included  in  the  "  middle 
ear,"  so  that,  strictly  speaking,  a  portion  of  the  mastoid  part 
of  the  middle  ear  is  situated  beyond  the  membrana  tympani. 
Inflammations  of  the  mastoid,  in  not  unfrequent  cases,  occur 
with  no  perforation  of  the  membrana  tympani,  and  the  pus 
evacuates  itself  in  the  auditory  canal. 

The  importance  of  these  relations  was  first  fully  pointed  out 
by  Yon  Troltsch. 


Fig.  7. 


C.GI.M. 


M.A.E- 


Pr.Ji/ 


Vertical  Section  of  the  Osseous  Meatus,  right  side,  close  to  the  Membrana  Tympani.    After 

Von  Troltsch. 

M.  A.  E.  External  auditory  canal.  C,  gl,  m.  Articular  fossa  of lower  jaw.  Sq.  Inner  part  of 
the  squamous  portion  of  the  temporal  bone.  The  dura  mater  has  been  removed.  F.  S. 
Fossa  sigmoideafor  the  sinus  transversus.    Pr.  M.  Mastoid  process. 


BLOOD-VESSELS  OF  THE  AUDITORY  CANAL. 

1.  Posterior  auricular  artery,  which  also  supplies  the  au- 
ricle. 

2.  Deep  auricular,  from  the  internal  maxillary.     It  enters 

5 


6Q  AUTHOEITIES. 

at  the  articulation  of  the  lower  jaw,  supplies  the  tragus,  and 
then  gives  off  branches  to  the  canal. 

NERVES. 

1.  From  third  branch  of  the  tri-facial  or  fifth  nerve.  These 
enter  through  the  anterior  wall,  between  the  cartilaginous  and 
osseous  portions. 

2.  An  auricular  branch  from  the  pneumogastric,  which 
enters  the  anterior  wall  of  the  bony  canal. 

This  auricular  branch  was  first  described  by  Arnold  in  1828. 

The  effect  of  irritation  of  this  branch  is  often  seen  by  the  cough  produced 
when  the  aural  speculum  is  pressed  upon  it,  or  when  the  part  is  touched  by 
a  probe. 


AUTHOEITIES. 

Gray,  Henry.  Anatomy,  Descriptive  and  Surgical.  Second  American 
Edition,  1862.     (Reprint.)    Philadelphia. 

G1)  tiber,  J.     Lehrbuch  der  Ohrenheilkunde.     Wien,  1870. 

Jlenle,  J~.     Anatomie  des  Menschen.     Braunschweig,  1866. 

JZyrtl,  J~.     Lehrbuch  der  Anatomie  des  Menschen.    Wien,  1862. 

ICessel,  J~.  The  External  Ear  in  Strieker's  Manual  of  Histology.  Trans- 
lated by  J.  Orne  Green.     New  York,  1872. 

Yo?i  Troltsc7i.  Treatise  on  the  Diseases  of  the  Ear,  including  the  Anatomy 
of  the  Organ.    American  Translation.    New  York,  1869. 


CHAPTER    III. 

THE  EXAMINATION  OP  AURAL  PATIENTS. 

It  is  a  self-evident  proposition,  that  in  order  to  intelli- 
gently treat  any  disease,  we  must  carefully  and  thoroughly 
examine  the  parts  involved.  This  is  certainly  as  true  of 
the  affections  of  the  ear  as  it  is  of  those  of  any  other  organ. 
In  making  such  an  examination  a  definite  plan  should  be 
followed,  even  in  the  seemingly  simple  cases,  until  at  last 
a  large  experience  enables  the  practitioner  to  omit  or  hurry 
over  some  of  the  details  which  were  necessary  in  the  begin- 
ning of  his  practice. 

In  the  examination  of  an  aural  patient,  the  following 
method  is  the  one  that  I  have  found  very  useful : — I  usually 
keep  a  record  of  the  cases ;  a  plan  which  the  young,  and  con- 
sequently not  very  busy,  practitioner  will  find  extremely  valu- 
able. The  name,  age,  and  occupation  of  the  patient  are  noted. 
The  history  should  then  be  given.  This  history  should  include 
a  pretty  full  statement  of  the  general  condition,  the  diseases 
from  which  the  patient  has  suffered,  the  number  of  times  he 
has  had  what  is  called  "  ear-ache,"  the  medication  to  which 
he  has  been  subjected,  and  so  on,  from  his  earliest  recollec- 
tions until  the  date  of  his  coming  under  observation  as  an 
aural  patient. 

By  no  other  means  than  by  eliciting  such  a  history,  can 
the  practitioner  get  the  essential  knowledge  for  a  thorough 
understanding  of  the  subjective  manifestations  of  the  affec- 
tion of  the  ear.  It  is  very  important  to  ascertain  when  the 
troublesome  symptoms  were  first  observed.  Sometimes  sev- 
eral minutes  will  be  consumed  in  obtaining  an  answer  to  this 
question.  The  first  reply  will  be,  perhaps,  "A  few  months 
ago,"  or,  "  A  year  or  two."     If  this  response  be  followed  by 


68  EXAMINATION  OF  AUKAL  PATIENTS. 

the  inquiry,  "  Before  that  time  were  your  ears  perfectly  well  ?  " 
in  many  instances  the  patient  will  state,  "  Well,  no.  I  have 
had  a  little  dulness  of  hearing  on  one  side,  for  ten  or  twelve 
years,  or  for  a  good  while"  (which  proves  to  be  a  number  of 
years)  ;  or  perhaps  he  says,  "  There  has  been  a  little  discharge 
from  that  ear,  'which  didn't  amount  to  much,'  ever  since  I 
had  the  scarlet  fever  or  the  measles."  As  illustrative  of  this 
point,  I  may  mention  a  case  which  lately  came  to  my  clinic ; 
the  patient,  an  old  man,  gave  the  following  history :  While 
sitting  quietly  by  the  fire,  blood  began  to  run  from  his  ears, 
until  he  had  lost  quite  an  amount  ;  he  stated  positively  that 
this  was  the  first  time  in  all  his  long  life  that  he  had  ever 
been  affected  with  an  affection  of  the  ear,  and  that  he  could 
imagine  no  cause  for  it.  On  close  examination  in  the  man- 
ner of  questioning  above  indicated,  he  admitted  that  he  had 
suffered  from  a  "slight  running  from  the  ears,  which  didn't  sig- 
nify, ever  since  he  was  a  child."  An  inspection  of  the  organs 
showed  that  both  membranes  tympani  were  removed  by 
ulceration,  and  that  exuberant  granulations  existed,  which  ac- 
counted for  this  seemingly  mysterious  hemorrhage,  to  which 
the  patient  could  assign  no  cause. 

It  is  well  in  obtaining  the  history  to  allow  the  patient  to 
tell  his  own  story,  occasionally  interrupting  him,  as  may  be 
necessary,  in  order  to  keep  him  to  the  matter  in  hand.  After 
having  thus  obtained  as  accurate  an  account  as  possible,  the 
next  step  is  to  test  the  amount  of  hearing.  We  have  three 
tests  for  the  hearing  power  : 

1.  Ordinary  conversation. 

2.  The  tick  of  a  watch. 

3.  The  tuning-fork. 

The  first  of  these  tests,  the  power  of  hearing  conversa- 
tion, perhaps  tells  the  most  about  a  person's  practical  hearing 
power,  and  yet  it  is  the  one  that  is  carried  out  with  most  diffi- 
culty. There  are  many  persons  who  can  hear  the  tick  of  an 
ordinary  watch  but  a  short  distance,  say  six  inches,  and  yet 
are  able  to  hear  ordinary  conversation  with  some  ease ;  and 
on  the  other  hand,  there  are  others  who  can  hear  the  same 
watch  twice  as  far,  but  who  are  utterly  unable  to  enjoy  con- 
versation carried  on  in  an  ordinary  tone.     About  the  best  test 


THE  WATCH  AS  A  TEST    OF   HEAEING.  69 

of  the  hearing  power  that  we  have,  is  the  one  which  shows  the 
patient's  capability  for  hearing  what  is  said  in  social  inter- 
course, at  the  table,  in  the  drawing-room,  and  so  on.  Inas- 
much, however,  as  practitioners,  especially  those  who  live  in 
large  cities  or  towns,  have  not  always,  or  even  usually,  the 
opportunity  of  making  such  a  test  of  their  patient's  hearing 
capabilities,  and  since  the  amount  of  this  power,  although  it 
may  be  appreciated  by  the  observer  himself,  cannot  be  made 
clear  to  one  who  simply  reads  the  case,  we  are  obliged,  in 
recording  the  histories  of  patients,  to  be  content  with  a  state- 
ment as  to  how  far  an  ordinary  ticking  watch  may  be  heard, 
or  at  what  distance  words  can  be  understood  when  they  are 
directed  to  the  person  observed,  with  his  face  so  placed  that 
he  cannot  see  the  mouth  of  the  speaker.  This  latter  pre- 
caution is  an  essential  one,  since  all  persons  with  impaired 
hearing  soon  learn  to  watch  the  lips  of  the  speaker,  in  order 
to  compensate  for  their  loss  of  hearing  power. 

In  testing  the  hearing  by  means  of  the  watch,  it  should 
be  first  placed  at  a  distance  at  which  its  ticking  cannot 
be  heard  by  the  patient,  and  then  gradually  approached 
to  a  situation  where  the  ticks  can  be  accurately  counted. 
The  latter  may  fairly  be  considered  as  the  farthest  point  of 
distinct  hearing.  The  ear  which  is  not  being  tested  should 
be  closed  during  the  examination  by  the  hand.  It  is  hard  to 
state  the  distance  at  which  a  watch  should  be  heard  by  a 
healthy  ear,  for  the  simple  reason  that  different  watches  may 
be  heard  at  different  distances,  so  varying  is  the  distinctness 
of  the  tick.  It  may  be  approximately  stated,  however,  that 
an  ordinary  ticking  watch  should  be  heard,  by  a  person  with 
average  hearing  power,  at  least  four  feet.  To  this  rule  there 
are,  however,  exceptions.  For  instance,  I  know  a  medical 
gentleman  in  this  city,  who,  as  tested  by  the  ordinary  transac- 
tions of  professional  and  social  life,  is  not  at  all  hard  of  heat- 
ing, who  cannot  hear  a  watch  of  common  tone  more  than  six 
inches.  Exact  examination  would  undoubtedly  show  that  this 
gentleman's  hearing  is  defective  with  regard  to  all  tones  like 
those  of  a  watch. 

In  testing  the  hearing  power  by  means  of  a  watch,  it  is  well 
to  remember,  as  Von  Troltsch  suggests,  that  all  watches  are 


70  REGISTER  OF  HEARING  POWER. 

heard  better  immediately  after  they  are  wound,  and  also  that  the 
intensity  of  their  sound  is  increased  by  holding  them  so  that 
the  surgeon's  hand  covers  the  back,  or  when  they  are  held  by 
the  patient's  own  hand.  In  the  two  latter  instances  the  cause 
of  the  increased  clearness  of  the  tick  is,  in  the  one  case,  the 
retardation  of  the  reflection  of  sonorous  waves  from  the  watch, 
and  in  the  other,  the  conducting  power  of  the  patient's  own 
arm  as  it  is  stretched  out. 

The  use  of  a  tape  or  other  measurer,  to  note  the  number 
of  inches  at  which  the  watch  is  heard,  is  indispensable  for  an 
accurate  record  of  a  case.  The  measure  should  not  be  used, 
however,  until  the  distance  has  been  ascertained  without  it. 

When  the  patient  cannot  hear  the  watch  at  any  distance 
from  the  ear,  it  should  be  laid  or  pressed  upon  the  auricle, 
mastoid  process,  or  forehead.  Before  using  a  watch  for  the 
purpose  of  testing  the  hearing  power  of  diseased  ears  we 
should  carefully  ascertain  how  far  it  may  be  heard  by  persons 
whose  hearing  is  unimpaired. 

My  friend  Dr.  J.  S.  Prout,  Surgeon  to  the  Brooklyn  Eye 
and  Ear  Hospital,  has  greatly  facilitated  our  means  of  record- 
ing the  hearing  power,  by  a  simple  method,  which  is  some- 
what analogous  to  that  used  in  estimating  the  acuteness  of 
vision ;  but,  as  Dr.  Prout  says,*  "  the  accuracy  with  which  we 
measure  the  visual  power  by  Snellen's  test  types,  and  record 
the  results  obtained,  cannot  be  arrived  at  by  means  of  any  of 
the  usual  sound-makers  (sonof actors) ;  nor  will  it  be  until  an 
instrument  can  be  made  which  shall  always  produce  uniform 
tones."  Dr.  Prout  recommends  a  formula  for  registering  the 
hearing  power,  which  he  describes  as  follows :  "  For  nearly 
three  years  I  have  recorded  the  hearing  power  as  a  fraction, 
the  numerator  of  which  is  the  distance  at  which  the  particular 
sound  is  heard,  the  denominator  the  distance  at  which  it 
should  be  heard  by  an  ear  of  good  average  hearing  power. 
This  denominator  must  vary  according  to  the  sonofactor  used, 
and  should  generally  be  expressed  in  inches. 

"For  still  further  simplification,  and  that  the  method  may 
be  adapted  to  international  use,  I  suggest  the  following  abbre- 
viations :  A.  D.,  auris  dextra,  instead  of  right  ear,  or  R.  E. ; 
*  Boston  Medical  and  Surgical  Journal,  Feb.  29, 1872. 


REGISTER  OF  HEARING  POWER.  71 

A.  S.,  auris  sinistra ;  P.  A.,  P.  aucL,  potentia  auditus,  hearing 
power ;  V.,  vox,  the  spoken  voice  ;  Y.  S.,  vox  susurrata,  whis- 
pered voice — or  simply  S.,  susurrus,  a  whisper ;  H.,  horolo- 
giuni,  the  watch. 

"  If  this  system  should  become  general,  then  the  formula 
P  A,  A  D,  H,  =  ||,  would  to  all  otologists  represent  the  fact 
that  a  watch  that  should  be  heard  at  36  inches  was  heard  by 
the  right  ear  of  the  patient  at  a  distance  of  12  inches ;  the 
formula  P  A,  A  S,  V  S,  =/@,  would  mean  that  the  whispered 
voice  was  heard  by  the  left  ear  at  6  inches  that  should  have 
been  heard  at  36  inches." 

I  have  employed  Dr.  Prout's  method  (more  or  less)  for 
some  years.  My  own  watch  can  be  heard  by  a  person  with 
good  hearing  power,  at  least  48  inches.  It  will  be  seen  that 
if  I  wish  to  express  the  hearing  power  of  a  person  who  hears 
that  watch  one  inch,  I  would  use  the  fraction  ¥\,  and  so  on. 
If  the  patient  only  hears  the  watch  when  brought  in  contact 
with  the  ear,  we  may  employ  the  formula  ¥CB  ;  if  only  on  pres- 
sure, /g- ;  if  not  at  all,  ?°g. 

THE  TUNING-FOEK. 

The  tuning-fork  is  of  value  in  determining  if  any  disease 
of  the  auditory  nerve  exists,  and  if  so,  whether  its  lesion  pre- 
dominate over  the  affection  of  the  outer  parts  of  the  ear. 

As  is  well  known,  if  we  close  our  ears,  and  speak,  the 
sound  of  the  voice  seems  to  be  confined  to  the  head,  as  it 
were  ;  its  reflection  being  to  a  certain  extent  prevented  by  the 
closure  of  the  external  auditory  canal.  If  now  the  auditory 
nerve  be  sound,  and  there  be  impacted  wax  in  one  auditory 
canal,  or  a  thickening  of  the  mucous  membrane  lining  the 
cavity  of  the  tympanum,  the  state  of  things  will  be  similar  to 
that  when  the  external  meatus  of  a  healthy  ear  is  closed  by 
the  finger,  or  by  some  similar  means,  and  the  vibration  of 
the  tuning-fork  will  be  heard  more  distinctly  by  an  ear  thus 
affected  than  by  the  sound  one.  If  the  ears  are  equally 
affected,  it  will  be,  of  course,  more  difficult  to  come  to  a  con- 
clusion. If  the  nerve  be  seriously  impaired,  either  primarily 
or  secondarily,  by  disease  which  has  extended  from  the  mid- 


72  VALUE  OF  THE  TUNING-FORK. 

die  ear,  no  such  marked  difference  will  be  noticed  when  the 
external  meatus  is  closed. 

Again,  when  the  tick  of  a  watch  cannot  be  heard  at  all,  if 
the  auditory  nerve  be  not  seriously  impaired,  the  vibrations  of 
the  tuning-fork,  when  its  handle  is  placed  on  the  teeth,  fore- 
head, or  mastoid  process,  will  be  distinctly  heard ;  while  if 
the  nerve  be  the  seat  of  serious  lesion,  so  that  absolute  deaf- 
ness exists,  these  vibrations  will  not  be  at  all  perceived  in 
the  head.  Some  deaf-mutes,  who  were  born  deaf,  and  proba- 
bly with  a  disease  of  the  central  apparatus,  have  assured  me 
that  they  always  felt  the  sound  of  the  tuning-fork  passing  to 
the  region  of  the  diaphragm  or  stomach,  and  they  would  in- 
voluntarily place  their  hand  there  when  the  vibration  began. 
The  large  tuning-forks  of  the  note  C  are  to  be  preferred  to  the 
smaller  ones. 

There  is  one  source  of  error  in  the  use  of  the  tuning-fork 
that  cannot  be  fully  avoided.  Patients  who  do  not  have  fair 
habits  of  observation  will  say  that  they  hear  the  tuning-fork 
better  from  the  better  ear,  because  they  think  that  they  ought 
to  do  so.  A  little  care  in  urging  such  persons  to  notice  the 
sound  carefully  will  usually  cause  a  correct  answer  to  be  given. 
Its  chief  value  is,  however,  among  persons  who  can  be  taught 
to  observe  what  they  actually  hear,  and  who  will  allow  their 
theoretical  notions  to  remain  in  abeyance  for  a  time.  As  Dr. 
Prout  intimates,  the  great  desideratum  is  an  instrument  which 
will  give  the  same  number  of  vibrations,  of  the  same  pitch 
and  tone  under  the  same  conditions.  It  should  also  be  a 
portable  instrument,  and  which  can  be  multiplied  with  accu- 
racy to  any  number  that  may  be  wanted  by  those  who  test 
hearing  power. 

An  interesting  case  occurred  in  my  practice  last  spring, 
which  shows  the  value  of  the  tuning-fork  in  cases  of  slight 
impairment  of  hearing,  and  also  exhibits  the  inadequacy  of 
the  watch  as  a  test  of  hearing  power. 

Dr.  W.,  set.  33,  consulted  me  March.  12, 1872,  in  regard  to  an  uncomfortable, 
"  stuffy  "  sensation  in  the  right  ear,  attended  by  a  slight  impairment  of  hear- 
ing. His  history  was  that  he  had  had  nasal  catarrh  for  some  months ;  for  two 
days  he  has  observed  the  aural  trouble.  On  testing  the  hearing  power  by  the 
watch,  it  was  found  to  be  normal,  or  f  f  on  both  sides ;  but  the  tuning-fork  was 
heard  better  on  the  affected  side,  and  the  patient,  a  busy  physician  and  an  exact 


VALUE   OF  THE   TUNING-FORK.  73 

observer,  was  sure  that  his  hearing  power  was  somewhat  impaired  upon  the 
right  side,  although  the  watch  did  not  detect  it.  The  membrana  tympani  was 
slightly  injected  along  the  handle  of  the  malleus. 

I  diagnosticated  the  affection  as  sub-acute  inflammation  of  the  middle  ear 
of  the  right  side,  and  treated  it  by  the  use  of  the  Eustachian  catheter,  Polit- 
zer's  method,  and  a  gargle,  as  well  as  by  the  application  of  a  leech  to  the 
tragus.  After  the  first  use  of  the  catheter  and  Politzer's  method,  the  tuning- 
fork  was  heard  with  equal  distinctness  on  both  sides,  thus  confirming  the 
diagnosis  and  illustrating  the  value  of  the  test.  The  patient  recovered  per- 
fectly in  a  few  days  ;  but  at  each  visit  before  the  ear  was  inflated  until  his  ear 
was  fully  restored  to  the  normal  condition,  the  tuning-fork  was  heard  more 
distinctly  on  the  affected  side. 

According  to  Politzer,*  E.  H.  Weber  was  the  first  to  show 
the  facts  that  have  been  stated  with  regard  to  the  increase  in 
intensity  of  the  sound  of  a  tuning-fork,  on  the  side  of  the 
meatus  that  is  closed  by  the  finger.  Mach,  quoted  by  Politzer, 
explained  this  fact  by  the  theory  that  the  reflections  of  the 
waves  of  sound  from  the  ear  was  prevented  by  this  closure 
of  the  auditory  canal.  Politzer  concludes,  as  the  result  of 
experiments,  which  may  be  found  in  detail  in  the  first  vol- 
ume of  the  Archiv  fur  Ohrenheilkunde,  that  the  increased  per- 
ception of  sound  that  is  felt  in  one  ear  depends  upon  two 
causes : 

1.  The  waves  of  sound  that  have  been  carried  from  the 
bones  of  the  skull  to  the  air  of  the  external  auditory  canal 
are  reflected  back  on  the  membrana  tympani  and  ossicula 
auditus. 

2.  In  accordance  with  Mach's  theory,  the  passing  out  of 
the  waves  of  sound  which  have  reached  the  labyrinth  and 
cavity  of  the  tympanum,  through  the  bones  of  the  head,t  is 
prevented  by  the  obstacle  they  meet  in  the  closed  ear. 

It  will  thus  be  seen  that  Mach  and  Politzer  explain  the 
phenomenon  of  increased  perception  of  sounds  conveyed 
through  the  skull,  in  an  ear  whose  peripheric  portions  are 
obstructed  by  disease,  or  by  some  mechanical  cause,  entirely 
by  the  theories  that  the  loss  of  sound  is  prevented  by  the 
obstruction  to  its  reflection  from  the  auditory  canal,  and  that 
the  force  of  the  waves  is  also  intensified  by  their  being  thrown 
back  upon  the  nerve. 

*  Reprint  from  Wiener  Medizinischen  Wochenschrift. 

f  Archiv  fur  Ohrenheilkunde,  B.  I.,  p.  821,  1868.    Politzer,  1.  e. 


74  YALTJE  OF  THE  TUMNG-FOEK. 

Erhard*  believes  tliat  the  increased  intensity  of  the  sound 
in  an  ear  whose  outer  opening  is  closed,  is  due  to  the  fact  that 
the  force  or  impression  of  sounds  that  otherwise  disturb  and 
distract  the  mind,  is  diminished  by  the  closure  of  the  meatus. 
This  reasoning  seems  to  me  plainly  fallacious. 

Cases  of  disease  of  the  middle  ear  that  are  connected  with 
disease  of  the  labyrinth,  or  cases  in  which  the  middle  ear  is 
sound  on  one  side,  while  the  nerve  is  affected,  and  just  the 
opposite  state  of  things  exists  on  the  other  side — that  is,  the 
middle  ear  is  diseased  and  the  nerve  sound — will  of  course  ren- 
der the  value  of  the  tuning-fork  less  positive,  and  a  differen- 
tial diagnosis  difficult. 

Dr.  Politzerf  attempted  to  make  the  tuning-fork  test  more 
objective,  that  is  to  say,  less  dependent  upon  the  statement  of 
the  patient,  by  the  use  of  a  diagnostic  tube  with  three  arms. 
The  patient  has  one  in  each  ear,  while  the  surgeon  alternately 
interrupts  the  sound  communicated  by  the  vibrating  tuning- 
fork  through  these  arms  to  his  own  ear,  by  compressing  one 
of  them  with  the  finger. 

If  the  sound  of  the  tuning-fork  be  heard  to  pass  more  dis- 
tinctly through  one  branch  or  arm  than  the  other,  it  is  con- 
cluded that  there  is  some  obstruction  in  the  middle  ear  of  that 
side,  which  intensifies  the  impression  of  sound  produced  on 
the  sensorium  of  the  listener  as  well  as  that  of  the  patient. 

As  I  understand  Politzer's  objective  test,  the  ear  of  the 
examiner  is  placed  in  the  same  condition  as  that  of  the  pa- 
tient. If  it  be  applied  to  a  person  in  whom  we  are  positively 
certain  that  the  lesion  is  in  the  canal  or  middle  ear,  and  when 
the  patient  hears  it  more  distinctly  on  that  side,  the  sound 
from  the  corresponding  arm  of  the  tube  will  usually  be  inten- 
sified to  the  listener. 

I  have  placed  a  plug  of  cotton  in  one  meatus  of  a  person 
whose  ears  were  of  equally  good  hearing  power,  and  have  then 
used  Dr.  Politzer's  triple-armed  diagnostic  tube,  and  thus  far  I 
have  heard  the  sound  more  intensely  in  the  arm  of  the  tube 
that  was  in  the  plugged  meatus.  Other  observers  have  at 
times  come  to  a  different  conclusion  in  the  case  of  the  person 

*  Klinische  Otiatrie,  p.  88. 

•j-  Archiv  fur  Olirenueilkunde,  1.  c. 


TUNING-FORK   IN   DIAGNOSIS.  75 

whom  I  examined  in  this  way,  so  that  the  test  is  not  wholly 
reliable. 

It  requires  too  many  precautions  to  be  generally  available. 
It  is  valuable  as  a  physiological  test,  however. 

The  diagnosis  of  a  slight  impairment  of  the  caliber  of  the 
Eustachian,  which  is  always,  as  I  believe,  attended  by  more 
or  less  catarrh  of  the  tympanic  cavity,  is  rendered  easier  by 
the  use  of  the  tuning-fork,  as  was  illustrated  by  the  case  on 
the  preceding  page. 

If,  however,  in  a  decided  case  of  catarrh  of  the  middle  ear, 
the  tuning-fork  is  heard  better  on  the  normal  side,  we  must 
conclude  that  there  is  some  lesion  of  the  labyrinth — perhaps  as 
Politzer  *  and  Schwartze  suggest,  "  a  fluxion  towards  the  laby- 
rinth with  serous  exudation  in  the  nerve  structure."  In  cases 
of  this  kind,  as  the  pressure  upon  the  labyrinth  is  removed  by 
a  decrease  of  the  catarrh  of  the  middle  ear,  the  tuning-fork 
will  be  heard  better  on  the  affected  side. 

Politzer  t  explains  the  fact  that  in  some  cases  of  perfora- 
tion of  the  membrana  tympani,  the  tuning-fork  is  heard  better 
on  the  affected  side  by  two  reasons  : 

1.  The  mobility  of  the  ossicula  auditus,  by  which  the  pas- 
sage outward  of  the  waves  of  sound  that  have  once  reached 
the  labyrinth  is  retarded,  is  lessened. 

2.  By  the  perforation  of  the  drum-head,  the  cavity  of  the 
tympanum  and  auditory  canal  are  converted  into  one  space, 
and  a  greater  resonance  from  the  larger  air-chamber  is  pro- 
duced, which  acts  upon  the  fenestras,  ovcdis  and  rotunda,  and 
increases  the  intensity  of  the  perceptive  power  of  the  labyrinth. 

The  tuning-fork  used  by  Politzer  in  his  experiments  and 
in  his  practice,  corresponds  to  the  second  C  in  the  base, 
vibrating  512  times  in  the  second.  On  striking  it,  we  notice 
particularly  two  distinct  tones — one  the  ground  tone  or  domi- 
nant, the  other  the  upper  tone  or  musical  fifth ;  either  one  or 
the  other  predominates,  according  to  the  density  of  the  sub- 
stance against  which  the  tuning-fork  is  struck.  In  employing 
it  for  diagnosis,  the  predominance  of  the  upper  tone  is  often 
very  confusing  to  the  patient,  and  the  cause  of  error. 

*  L.  c.,  p.  5.  f  L.  c,  p.  12. 


76 


BLAKE  S   TUNING-FOEK. 


Fig.  8. 


In  order  to  get  the  pure  dominant,  it  is  only  necessary  to 
affix  a  pair  of  metal  clamps  to  the  ends  of  the  branches ; 
this  is  done  by  means  of  small  screws.  If  the  tuning-fork  is 
now  struck  even  with  a  hard  substance,  only  the  dominant 
is  perceptible.  Dr.  Schaar,*  of  Vienna,  diminishes  the  inten- 
sity of  the  upper  tone  by  gentle  pressure  upon  the  lower  por- 
tion of  the  branches. 

The  value  of  the  tuning-fork  in  testing  the 
perception  of  different  musical  tones  has  been 
much  increased  by  the  discovery  that,  by  fix- 
ing the  clamps  at  different  points  upon  the 
branches,  it  is  possible  to  obtain  all  the  tones 
and  semitones  up  to  an  octave  above  the  musi- 
cal fourth  of  the  dominant  tone  of  the  tuning- 
fork. — (Politzer. ) 

Dr.  Blake  ,t  who  has  written  a  good  digest 
of  this  subject,  says  that  "  Itard  used  a  bell 
which  was  struck  by  a  pendulum,  the  force  of 
the  blow  being  determined  by  the  space  through 
which  the  pendulum  passed  before  striking ;  in 
this  way  the  difficulty  as  to  control  of  the  inten- 
sity of  the  sound  was  overcome,  but  the  tone 
remained  the  same."  Following  this  idea,  Dr. 
B.  caused  to  be  constructed  the  tuning-fork  as 
represented  in  the  accompanying  wood-cut 
(one-third  size),  that  is,  the  common  instrument 
with  the  clamps  as  used  by  Dr.  Politzer,  but 
with  the  addition  of  a  hammer,  the  head  of 
steel,  one  face  being  covered  with  soft  rubber. 
"Luc?e  proposed  the  use  of  a  hammer  faced  with  some  elastic 
material  for  striking  the  tuning-fork.  The  handle  of  the  ham- 
mer is  a  steel  spring,  sliding  in  a  bar  affixed  to  the  stem  of 
the  fork,  and  fastened  in  place  by  a  small  set  screw.  By  using 
either  the  steel  or  rubber  face  of  the  hammer,  either  the  upper 
or  lower  tone  will  be  rendered  most  prominent.  By  affixing 
the  clamps  as  Politzer  directs,  we  obtain  the  variety  of  tone, 
and  by  the  distance  to  which  the  hammer  is  sprung  can  reg- 

*  Blake,  Reprint  from  Boston  Medical  and  Surgical  Journal,  p.  3. 
f  Blake,  1.  c. 


THE  INTERFERENCE   OTOSCOPE.  77 

ulate  their  intensity.  The  adjustment  is  simple,  and  obvi- 
ates the  necessity  of  employing  any  other  musical  instru- 
ment." 

THE  INTERFERENCE  OTOSCOPE. 

Dr.  August  Luces,*  of  Berlin,  proposes  a  new  method  of  examining  the 
ear  for  physiological  and  diagnostic  purposes  by  means  of  what  he  terms  the 
interference  otoscope — interference  apparatus  would  be,  I  think,  a  more  appro- 
priate term. 

Dr.  Lucse  proves  by  experiment  that  the  human  membrana  tympani  does 
not  receive  the  complete  intensity  of  the  waves  of  sound,  but  that  it  reflects  a 
portion  of  these  waves  ;  also,  that  with  the  increase  of  the  tension  of  the  mem- 
brana tympani,  the  reflection  outward  increases,  and  the  reception  of  the 
waves  inward  decreases.  He  then  describes  his  apparatus,  which  is  made 
after  that  of  G.  Quincke,  for  explaining  the  reflection  of  sound  waves. 

It  consists  of  a  vertically  placed  glass  tube,  of  about  10  inches  in  length,  in 
the  centre  of  which  is  a  joint  of  glass,  for  the  application  of  a  horizontal  tube 
of  gutta-percha,  which  is  placed  in  the  ear  of  the  person  to  be  examined.  The 
sounds  are  conveyed  through  the  upper  end  of  the  vertically  placed  glass  tube, 
to  the  bottom,  and  thence  through  a  second  rubber  tube  to  the  ear  of  the 
observer. 

The  lateral  or  horizontal  tube  passing  into  the  auditory  canal  of  the  person 
co  be  examined,  should  be  one-quarter  the  wave  length  of  the  sounds  that  are 
to  be  experimented  with.  (The  wave  length  from  a  tuning-fork  of  the  note  C 
is  48  Parisian  inches.) 

A  cork  with  a  handle  is  placed  in  the  end  of  the  lateral  glass  tube,  which 
can  be  pushed  backward  or  drawn  forward,  and  thus  increase  or  decrease  the 
length  of  this  tube  according  to  the  wave  length  of  the  sound  employed. 

As  will  be  seen,  the  sounds  divide  in  the  middle  of  the  tube  into  two  parts. 
One  part  passes  directly  down  to  the  ear  of  the  examiner  ;  the  other,  after  it 
has  been  reflected  from  the  end  of  the  lateral  glass  tube  that  is  stopped  by 
a  cork. 

Lucse's  apparatus  is  made  for  the  tone  C  with  264  vibrations.  Its  wave 
lengths  are  48  Paris  inches.  The  interference  piece  is  therefore  12  Paris 
inches  in  length. 

By  the  aid  of  this  apparatus,  experiments  were  made  on  a  glass  model,  the 
ears  of  a  dead  subject,  and  those  of  living  persons. 

For  the  sake  of  convenience,  Lucse  modified  his  apparatus.  It  now  con- 
sists of  a  double  otoscope,  like  the  differential  stethoscope  of  Scott  Allison. 
These  arms  are  attached  by  a  glass  tube,  shaped  liked  the  letter  X,  to  two 
tubes :  one  for  the  ear  of  the  examiner,  the  other  for  the  resonator  or  sound 
receiver  into  which  the  arms  of  the  tuning-fork  look.  The  fork  is  placed  on  a 
stand  and  caused  to  vibrate  by  means  of  a  hammer.  The  resonator  should  be 
made  of  paste-board.    The  metal  ones  may  injure  the  ear. 

*  Archiv  fur  Ohrenheilkunde,  Bd.  III. 


78  THE  INTERFERENCE  OTOSCOPE. 

The  interference  arras  are  also  made  of  gutta-percha.  By  alternately 
pressing  together  one  and  the  other  tube  of  the  double  otoscope  we  may  decide 
how  much  the  sonorous  waves  are  reflected  from  each  ear.  The  practical 
value  of  the  interference  diagnostic  tube  depends  upon  Lucse's  conclusion  that 
there  is  a  greater  reflection  of  the  waves  of  sound  of  the  worse  ear,  if  there 
be  disease  of  the  peripheric  parts  of  the  organ  of  hearing.  If,  however,  there 
is  a  weaker  reflection  from  the  worse  ear,  it  is  concluded  that  there  is  disease 
of  the  nerve.* 

Lucae's  theory  of  the  increase  in  intensity  of  a  sound  when  the  meatus  is 
closed,  or  when  there  is  peripheric  disease,  is  that  the  intra-auricular  pressure 
is  increased,  which  intensifies  all  sound,  although  it  may  prevent  their  being 
distinctly  perceived. 

If  this  were  so,  it  would  seem  that  all  persons  whose  hearing  is  impaired 
from  middle  ear  disease,  which  causes  a  secondary  pressure  upon  the  laby- 
rinth— for  example,  in  cases  of  anchylosis  of  the  stapes — should  be  disturbed  by 
the  intensity  as  well  as  the  indistinctness  of  sounds. 

Luccef  in  a  subsequent  article  amplifies  his  views  and  does 
not  accept  the  theories  of  Mach  and  Politzer,  that  the  closure 
of  the  canal  or  of  the  cavity  of  the  tympanum  prevents  the 
passage  of  the  waves  of  sound  outward.  Indeed  he  does  not 
believe  that  waves  of  sound  that  have  reached  the  labyrinth 
through  the  bones  of  the  skull,  return  through  the  membrana 
tympani  and  ossicles.  When  we  speak  of  the  exit  of  sound 
waves  from  the  ear,  we  can  only,  according  to  Lucce,  under- 
stand those  undulations  which  are  carried  to  the  air  of  the 
auditory  canal  from  its  walls  and  from  the  membrana  tym- 
pani. 

The  conduction  of  sounds  to  the  labyrinth  is  diminished 
by  increased  tension  of  the  membrana  tympani.  Still,  when 
this  increased  tension  causes  a  slight  but  positive  variation  in 
the  pressure  upon  the  labyrinth,  the  perception  of  deeper 
sounds  may  be  increased.  The  increased  intensity  of  sound, 
when  the  external  auditory  canal  is  closed,  chiefly  affects  the 
low  tones,  and  is  chiefly  to  be  explained  by  the  resonance  of 
the  short  column  of  air  in  the  passage. 

Lucse  admits  the  full  diagnostic  value  of  the  tuning-fork 

*  Herr  Schafer,  instrument  maker,  in  Berlin,  furnishes  Lucse's  inter- 
ference otoscope  for  3  Prussian  thalers ;  the  C  tuning-fork  for  5  thalers  and 
10  silver  groschens ;  the  resonator  or  sound  receiver  for  2  thalers  and  15 
groschens.     The  whole  apparatus  would  therefore  cost  about  $10  in  gold. 

f  Archiv  fiir  Ohrenheilkunde,  Bd.  V.,  p.  98. 


VON  conta's  method.  79 

for  all  cases  of  peripheric  disease,  such,  as  impacted  cerumen, 
affections  of  the  cavity  of  the  tympanum,  if  one  side  only  be 
affected,  and  he  says  that  in  all  such  cases,  where  the  prognosis 
is  good,  the  tuning-forks  C,  C,  C,  placed  on  any  part  of  the 
skull,  will  be  heard  better  on  the  affected  side ;  but  he  does 
not  accept  the  theories  of  Mach  and  Politzer  to  explain  this 
phenomenon,  and  he  limits  the  value  of  the  tuning-fork  in 
diagnosis  to  acute  and  dangerous  suppurative  inflammations 
of  the  middle  ear,  in  which,  if  the  tuning-fork  be  constantly 
heard  better  on  the  affected  side,  the  brain  is  not  in  danger. 


VON  CONTA'S  METHOD. 

Von  Oonta,*  of  Weimar,  some  years  since,  recommended 
that  the  tuning-fork  be  used  to  the  exclusion  of  the  watch,  in 
testing  the  hearing  distance.  In  his  method  an  elastic  tube  is 
used  through  which  the  waves  of  sound  are  conducted,  instead 
of  through  the  uninclosed  air.  The  number  of  seconds  or 
minutes  during  which  the  gradually  decreasing  vibrations 
of  the  tuning-fork  are  heard,  becomes  the  measure  of  the 
hearing  power.  The  fork  is  struck  upon  the  knee  of  the 
examiner,  and  then  immediately  placed  in  the  outer  extremity 
of  the  tube,  which  has  been  previously  placed  in  the  pa- 
tient's ear.  The  instant  he  ceases  to  hear  the  vibrations  he 
informs  the  surgeon  by  the  word  "  now,"  who  has  noted  the 
time  with  the  watch  in  hand,  when  the  fork  was  placed  in 
the  tube. 

This  method  is  certainly  not  without  value,  but  the  desid- 
eratum, namely,  a  method  by  which  the  ability  to  hear  sounds 
resembling  the  human  voice  may  be  accurately  estimated,  is 
yet  to  be  obtained. 

In  testing  the  visual  power  we  have  exact  means  which 
indicate  the  practical  loss  of  sight  which  the  patient  may  have 
suffered.  It  is  to  be  hoped  that  the  physiology  of  acoustics 
may  at  no  distant  day  present  us  one  for  the  accurate  estima- 
tion of  a  loss  of  hearing  power. 

*  Archiv  far  Olirenheilkunde,  Bd.  I. 


80 


AURAL  SPECULA. 


EXAMINATION  OF  AUDITORY  CANAL  AND  MEMBRANA  TYMPANI. 

The  next  step  after  noting  the  hearing  power  in  the  exam- 
ination of  our  imaginary  patient,  is  the  exploration  of  the 
auditory  canal  and  the  membranse  tympani. 

It  is,  of  course,  implied  in  this  that  an  affection  of  the 
auricle  needs  no  special  assistance  for  examination. 

For  the  purpose  of  examining  the  external  auditory  canal 
three  instruments  may  be  necessary :  a  pair  of  angular  for- 


Fig.  9. 


Angular  Forceps. 

ceps,  an  aural  speculum,  and  a  concave  mirror  or  reflector. 
The  first  is  of  use  to  remove  any  temporary  obstructions  which 
may  prevent  a  view  ;  the  second  dilates  the  canal ;  and  the 
third  throws  the  light  into  it. 

According  to  Wilde,*  Dr.  Newbourg,  in  a  memoir  pub- 
lished at  Brussels  in  1827,  recommended  an  instrument  which 
is  the  origin  of  all  the  tubular  ear  specula  now  in  use.  It  was 
a  slender  horn  tube,  four  inches  long,  with  a  bell-shaped  outer 

Fig.  10. 


amber's  Speculum. 

orifice.     Subsequently  this  instrument,  which  was  much  too 
long,  was  improved  by  shortening  it,  by  Dr.  Ignaz  Gruber,  of 


*  Treatise  on  Diseases  of  the  Ear,  p.  60. 


METHOD   OF   HOLDING   THE   SPECULUM.  81 

Vienna,  and  generally 'introduced  to  the  profession  by  Sir 
"William  Wilde,  in  1844.  After  a  fair  trial  of  the  bi-valvular 
instrument  of  Kramer,  and  the  funnel-shaped  one  of  Toynbee, 
I  now  use  the  conical  speculum,  either  that  of  Wilde,  Troltsch, 
or  Gruber.  I  do  not  think  that  any  one  of  these  has  any 
great  advantage  over  the  others.  The  practitioner  will  do  very 
well  with  any  one  of  them.  Too  much  stress  is  sometimes 
laid  on  a  little  change  in  shape.  I  prefer  that  the  interior  sur- 
face of  the  speculum  be  brilliant,  and  not  black,  as  those  of 
Gruber  are  sometimes  made. 

Those  who  consider  that  there  is  an  advantage  in  a  funnel- 
shaped  instrument,  will  find  the  one  here  figured  preferable 
to  Toynbee' s,  because  the  transition  from  the  wide  orifice, 
which  dilates  the  cartilaginous  part  of  the  canal  to  its  fullest 
extent,  to  the  narrower,  which  exposes  the  osseous  portion, 
is  gradual,  and  thus  prevents  the  reflection  of  many  rays  at 
this  point. 

The  speculum  should  be  made  of  coin  silver,  for  ordinary 
use.  For  the  purpose  of  applying  acids  or  caustics,  one  of 
hard  rubber,  porcelain,  or  glass  is  to  be  preferred. 

The  instrument  is  warmed  by  the  hand  before  being  used, 
and  then  inserted  gently  and  slowly  into  the  meatus  with  the 
right  hand,  and  held  in  position  by  the  thumb  and  index  fin- 
ger of  the  left,  which  will  keep  the  speculum  under  Complete 
control,  and  enable  the  examiner  to  turn  it  so  as  to  succes- 
sively view  the  different  parts  of  the  whole  surface  of  the 
membrana  tympani,  and  at  the  same  time  to  thoroughly 
straighten  the  canal  by  pushing  up  the  upper  wall  of  the 
canal. 

It  is  very  important  that  the  speculum  be  held  properly, 
for  I  have  seen  many  a  student,  for  the  want  of  knowledge  of 
this  simple  manipulation,  labor  for  a  long  time  without  get- 
ting any  view  of  the  membrane,  while  the  instrument  was  rest- 
ing on  some  portion  of  the  projecting  wall  of  the  meatus. 

Having  thus  dilated  the  canal,  the  light  may  be  thrown 
into  it  by  means  of  the  otoscope  or  reflector  of  Von  Troltsch, 
which  is  a  concave  mirror  of  about  three  inches  in  diameter, 
having  a  focal  distance  of  about  six  inches.  Ordinary  day- 
light is  the  best  source  of  illumination  for  this  mirror,  although 


82 


VON  TKOLTSCH  S    OTOSCOPE. 


sun  light,  lamp  light,  gas  light,  that  of  a  candle,  or  the  reflec- 
tion from  a  light-colored  wall,  may  each  be  made  available  in 
this  method  of  examining  the  outer  parts  of  the  ear.  This  is 
a  very  simple  process,  although  many  make  a  difficult  one  of 
it.  If  we  but  use  the  skill  we  acquired  in  our  juvenile  days  in 
throwing  a  dazzling  light  upon  a  desired  object  by  means  of 
a  bit  of  broken  mirror,  it  will  serve  us  in  good  stead  here. 
The  mirror  is  held  very  lightly  in  the  hand,  and  the  light  is 
condensed  upon  any  desired  part  by  a  very  slight  movement. 


Fig.  11. 


Method  of  holding  the  Speculum  in  Position. 

It  is  now  almost  universally  conceded  by  the  profession, 
that  this  method  is  altogether  the  best  that  has  yet  been  sug- 
gested for  the  examination  of  the  membrana  tympani.  It  has 
the  unequivocal  endorsement  of  such  otologists  as  James 
Hinton  of  London,  Schwartze  of  Halle,  Politzer  and  Joseph 
Gruber  of  Vienna.  It  was  first  introduced  to  the  profession 
at  large  by  Professor  Anton  Yon  Troltsch,  in  1855,  without  pre- 


Fig.  12. 


Von  Troltsch's  Otoscope,  actual  size. 


84 


METHOD   OF  EXAMINING  MEMBKANA  TYMPANI. 


vious  knowledge  that  it  had  been  suggested  by  others,  al- 
though Dr.  Hoffman,  of  Westphalia,  had  previously,  in  1841, 
used  an  ordinary  shaving  mirror  with  a  central  opening  for  the 
examination  of  the  ear.  Professor  Edward  Jaeger,  in  his  work 
on  Cataract  and  Cataract  Operations,  published  in  1853,  sug- 
gests that  his  ophthalmoscope  may  be  used  with  the  concave 
mirror  of  four  inches  focal  distance,  for  the  examination  of  the 

Fig.  13. 


Method  of  Examining  the  Auditory  Canal  and  Membrana  Tympani. 

external  auditory  canal.     I  have  also  been  informed  by  nu- 
merous practitioners  that  they  have  often  used  the  ophthalmo- 


METHOD   OP   EXAMINING   MEMBEANA   TYMPANI.  85 

scopic  mirror  for  examining  the  ear ;  but  in  spite  of  all  these 
statements,  and  the  fact  that  Frank,*  in  his  work  on  the  Ear, 
gives  a  sketch  of  Hoffman's  otoscope,  the  credit  of  the  introduc- 
tion into  general  use  of  the  concave  mirror  for  the  examination 
of  the  ear  as  certainly  belongs  to  Von  Troltsch,  as  the  inven- 
tion of  the  ophthalmoscope  to  Heinrich  Helmholtz.  It  is 
somewhat  surprising,  however,  that  after  the  description  which 
Frank  gives  in  his  text-book  of  Hoffman's  method,  and  the 
drawing  which  he  furnishes  of  the  mirror,  no  attention  was 
paid  to  the  subject  until  Von  Troltsch  revived  it,  without 
knowing  of  Hoffman's  apparatus. 

I  introduced  the  use  of  the  aural  mirror,  or  otoscope  as  it 
should  be  called,  into  the  practice  of  the  New  York  Eye  and 
Ear  Infirmary,  in  1863,  where  it  soon  superseded  all  other 
methods,  and  whence  it  has  been  very  generally  adopted  in 
the  United  States. 

It  may  be  safely  said  that  the  adoption  of  this  simple 
method  of  examination  has  done  more  for  the  scientific  and 
practical  study  of  aural  disease,  than  any  previous  suggestion 
in  this  department.  It  has  placed  within  the  hands  of  every 
practitioner  a  method  by  which  he  may,  in  a  few  minutes, 
learn  to  examine  a  membrane  which  not  a  few  physicians 
have  never  seen  on  the  living  subject. 

I  deem  it  unnecessary  to  describe  the  numerous  methods 
which  preceded  that  of  Von  Troltsch,  since  they  are  fast  be- 
coming obsolete,  and  their  description  belongs  rather  to  the 
history  of  otology  than  to  a  practical  treatise.  Even  the 
method  of  examination  by  means  of  the  direct  rays  of  the  sun, 
which  held  out  so  long  in  the  hands  of  some  practitioners,  has 
at  last  given  way  to  the  use  of  the  mirror  and  ordinary  day- 
light. 

It  is  sometimes  convenient  for  the  examiner  and  the  pa- 
tient to  sit  during  the  examination  of  the  membrana  tympani, 
and  sometimes  both  may  stand,  or,  as  I  usually  examine,  the 
patient  may  sit  in  a  revolving  chair,  while  the  surgeon  stands. 
The  position  of  the  patient  will  not  be  an  important  matter, 
so  long  as  a  good  illumination  is  thrown  into  the  canal.     A 

*  Practische  Anleitung,  zur  Erkentniss  der  Okrenlieilkuncte,  p.  49. 


86 


BINOCULAK  OTOSCOPE. 


forehead  band  is  essential  in  making  applications  to  the  ear, 
and  it  is  often  convenient  at  other  times.     I  cannot  see  any 


Fig.  14. 


Forehead  Band. 

great  advantage  in  the  various  complicated  and  expensive 
bands  with  ball-and-socket  joints,  but  I  use  a  simple  screw 
attachment  by  which  the  mirror  is  fastened  to  the  head-band. 
The  head-band  should  be  of  elastic  material,  such  as  india- 
rubber  webbed  cloth. 

Dr.  Dl  Ro&si*  in  a  very  recent  paper  on  binocular  otoscopy,  proposes  the 
use  of  a  microscopic  object-glass  set  at  an  angle  of  70°  in- a  spectacle  frame,  as 
a  simple  and  efficient  binocular  otoscope.  This  suggestion  has  just  met  my 
eye  as  this  volume  is  passing  through  the  press,  and  I  am  inclined  to  think 
that  it  is  a  very  useful  one.f 

Dr.  Di  Rossi 's  first  instrument  £  consisted  of  an  arrange- 
ment of  prisms  behind  a  concave  mirror.  The  prisms  are  plane, 
one  of  90°,  the  other  of  10°.  The  diameter  of  the  concave 
mirror  is  7  centimetres.     Its  focal  distance  is  16  centimetres. 

The  central  opening  in  the  mirror  is  of  an  elliptical  shape. 
The  instrument  differs  from  the  binocular  ophthalmoscope  of 
Dr.  Giraud  Teuton  in  the  following  respects  : 

1.  The  mirror  is  much  larger,  inasmuch  as  ordinary  day- 
light is  used  as  the  source  of  illumination. 

2.  The  focal  distance  is  less. 

3.  The  prisms  are  of  a  higher  degree. 

I  think  the  advantages  of  binocular  vision  in  examining 
the  ear  are  not  sufficient  to  atone  for  the  loss  of  simplicity  and 

*  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  VI,  No.  7. 
f  Mr.  H.  W.  Hunter,  optician,  will  furnish  the  apparatus. 
%  Monatsschrift  fur  Ohrenheilkunde,  No.  12,  1869. 


BLAKE  S  PRISMATIC   OTOSCOPE. 


87 


cheapness  in  the  instrument  used  for  examination  that  occurs 
when  the  binocular  otoscope  is  substituted  for  Von  Troltsch's 
monocular  concave  mirror.  A  little  practice  enables  the  sur- 
geon to  judge  with  sufficient  accuracy  as  to  the  depth  of  objects 
in  the  canal  or  upon  the  drum-head,  or  beyond  it,  upon  which 
he  is  operating  ;  for  it  is  only  in  operating,  for  example,  in 
puncturing  the  membrana  tympani,  that  I  have  ever  felt  any 
difficulty  in  judging  of  the  depth  of  the  surface  which  it  was 
desired  to  touch. 

Mr.  Edward  S.  Ritchie,  of  Boston,  at  the  suggestion  of 
Dr.  Clarence  J.  Blake,*  has  made  an  instrument  which  is 
designed  to  overcome  the  disadvantages  attending  the  exclu- 
sion of  one  eye  from  the  visual  act  in  operating  upon  the 
membrana  tympani : 

"  It  consists  of  a  hand  rubber  speculum  (Politzer's)  of  the 
largest  size,  fitted  with  a  metallic  rim,  to  which  is  attached  a 
revolving  prism  and  an  arm,  bearing  at  its  outer  end  a  lens 
of  about  an  inch  focus ;  this  arm  is  movable,  but  sufficiently 
firm  to  remain  fixed  at  any  angle  at  which  it  is  placed.  The 
prism  is  just  within  the  focal  dis- 
tance of  the  lens,  and  its  incident 
face  is  armed  with  a  small  metal 
shield,  having  an  opening  in  the  cen- 
tre corresponding  in  its  short  diam- 
eter to  the  diameter  of  the  pencil  of 
light  falling  upon  it  from  the  lens. 

"The  advantage  of  the  prism 
over  a  mirror  or  other  reflecting  sur- 
face is,  that  we  have  almost  total 
reflection  ;  and  but  little  of  the  light 
concentrated  upon  the  prism  by  the 
lens  is  lost. 

"  In  operating,  an  assistant  is  required  to  draw  the  auricle 
upward  and  backward,  and  keep  the  speculum  in  position, 
with  the  pencil  of  light  upon  the  opening  in  the  shield  of  the 
prism.  It  is  not  claimed  for  this  instrument  that  it  at  all 
supersedes  the  head  mirror  of  Von  Troltsch,  but  it  is  certainly 
of  great  advantage  in  the  more  complicated  operations,  where 
*  Late  Contributions  to  Aural  Surgery.    Boston,  1870. 


Fig.  15. 


Blake's  Operating  Otoscope, 


88  EXAMINATION   OF  PHARYNX. 

a  steady  and  uniform  illumination  is  indispensable.  The 
instrument,  as  a  whole,  weighs  only  about  one  hundred  and 
fifty  grains,  and  can  be  made  much  lighter ;  so  that  when 
once  firmly  inserted  in  the  meatus,  it  remains  in  position,  and 
there  is  no  necessity  for  holding  it  nor  fear  of  its  slipping  out 
of  place  during  the  operation." 

The  practitioner  will  often  be  obliged  to  examine  the  ear 
and  pharynx  of  a  patient  who  is  too  ill  to  get  up  from  the  bed. 
The  light  from  a  candle  then  becomes  a  very  convenient  and 
ample  means  of  illumination.  The  finest  changes  on  a  mem- 
brana  tympani  and  in  the  auditory  may  be  observed  by  the  aid 
of  the  otoscope  and  such  a  light. 

EXAMINATION  OP  THE  PHAEYNX  AND  EUSTACHIAN  TUBES. 

After  having  heard  the  patient's  history,  and  having  ascer- 
tained the  amount  of  hearing,  we  may  proceed  to  the  exami- 
nation of  the  pharynx  and  nares,  and  mouths  of  the  Eusta- 
chian tubes.  Although  the  profession  has  been  a  long  time 
in  coming  to  an  appreciation  of  the  fact,  it  is  now  generally 
conceded  that  the  starting-point  of  a  large  percentage  of  aural 
cases  is  in  these  parts. 

The  pharynx  is  best  examined  by  turning  the  patient's  face 
to  an  open  window,  and  holding  the  tongue  by  means  of  a 

Turck's  or  a  simple  hinge  specu- 
lum. Turck's  instrument  is  to  be 
preferred  to  others,  because  the 
hand  of  the  examiner  does  not 
obscure  the  view  in  its  use.  I 
often,  however,  use  a  reflector 
and  ordinary  daylight  for  an  in- 
spection of  the  pharynx,  and  it 
"*mnge  8pecuium.  nas  some  advantages  over  a  direct 

illumination. 
Some  surgeons  prefer  to  use  artificial  light  in  examining 
the  pharynx  as  well  as  other  parts  of  the  body,  but  I  much 
prefer  ordinary  daylight  for  all  examinations,  when  it  is  pos- 
sible to  use  it,  to  that  from  any  artificial  source,  or  to  the 
direct  rays  of  the  sun,  since  it  seems  to  me  that  the  natural 


RHINOSCOPY. 


89 


hues  are  thus  best  observed.     In  the  evening,  of  course,  arti- 
ficial light  must  be  used.     A  reflector  should  then  be  em- 

Fig.  17. 


m 

W 

Turclc's  Speculum. 

ployed.  It  is  well  to  have  the  reflector  attached  to  a  forehead 
band,  as  in  the  practice  of  rhinoscopy  or  pharyngoscopy, 
which  will  be  immediately  described ;  but  I  may  defer  any 
description  of  what  to  observe  on  examining  the  fauces  and 
pharynx  until  we  come  to  speak  of  pharyngeal  disease. 


RHINOSCOPY. 

Rhinoscopy,  as  a  practical  method  of  examining  the  pos- 
terior nares,  was  suggested  by  Sir  William  Wilde  in  his  treatise 
on  aural  surgery,  having  previously  been  spoken  of  by  Boz- 
zini,  as  a  possible  method  of  examining  the  parts  behind  the 
hanging  palate,  in  a  book  published  in  Weimar  in  1807.* 

Professor  Czermak,  of  Prague,  following  up  Turck's  inves- 
tigations on  the  larynx,  was  the  first  to  actually  introduce 
rhinoscopy  into  anything  like  general  use ;  while  Dr.  Semel- 
eder,  Surgeon  to  the  Gumpendorf  Hospital  in  Vienna,  and 
afterwards  Surgeon  to  the  Archduke  Maximilian,  while  in 
Mexico,  gave  us  the  first  full  account  of  what  was  to  be  ob- 

*  Laryngoscopy  and  Rhinoscopy.    By  F.  Semeleder.     Translated  by  Dr.  E. 
T.  Caswell,  1866. 


90 


RHINOSCOPY. 


served  by  this  means,  with  some  interesting  cases.  Voltolini, 
of  Breslau,  has  also  added  much  to  our  knowledge  of  the 
value  of  this  means  of  diagnosis. 

It  is  by  no  means  necessary  that  every  aural  patient  should 
be  examined  with  the  so-called  rhinoscope,  nor  will  the  most 
accomplished  manipulator  be  able  to  see  the  mouth  of  the 
Eustachian  tubes  in  every  case ;  but  every  one  who  attempts 
to  treat  the  disease  of  the  organ  of  hearing  will  find  his  diag- 
nosis very  often  facilitated  by  an  inspection  of  these  parts  ;  for 
example,  when  any  unusual  difficulty  is  experienced  in  enter- 
ing the  mouth  of  the  Eustachian  tube. 

For  the  practice  of  rhinoscopy  we  need  a  lamp,  or  other 
source  of  artificial  illumination,  a  small  mirror,  a  tongue  spa- 
tula, and  a  concave  mirror  that  may  be  attached  to  a  forehead 
band  or  placed  on  Semeleder's  spectacle  frame.  Any  brightly 
burning  lamp,  or  a  good  Argand  gas-burner,  will  answer  as  a 
source  of  illumination. 

Various  kinds  of  costly  apparatus  for  the  purpose  of  con- 


Fig.  18. 


Tobold's  Lamp.    After  Tobold. 


densing  the  light  have  been  suggested  and  employed.     If  the 
surgeon  be  not  satisfied  with  an  ordinary  lamp,  perhaps  the 


RHINOSCOPY.  91 

apparatus  of  Tobold  will  be  found  the  best.  In  some  in- 
stances, although  not  always,  an  instrument  for  holding  back 
the  uvula  is  required.  Various  appliances  have  been  suggested 
for  this  purpose,  nooses,  hooks,  spatulas,  and  so  on,  for  any 
of  which  a  surgeon  of  ordinary  tact  will  find  or  provide  a  sub- 
stitute when  wanted. 

It  is  above  all  things  requisite  that  the  patient  should  be 
tractable,  and  this  tractability  is  perhaps  more  common  than 
many  surgeons  imagine.  Those  who  precede  all  their  mani- 
pulations by  an  appeal  to  their  patients  to  be  very  quiet,  to  be 
sure  not  to  stir,  not  to  mind  a  little  pain,  etc.,  and  who  at  the 
same  time  make  a  great  show  of  instruments,  will  generally 
have  intractable  and  timid  patients  ;  but  he  who  goes  quietly 
to  work,  will  find  few  patients  that  will  not  submit  with  more 
or  less  patience  to  all  such  manipulations  as  are  required  in 
rhinoscopy,  the  use  of  the  Eustachian  catheter,  and  the  like. 

The  patient  being  seated  in  front  of  the  examiner,  with  a 
good  light  at  one  side,  the  mouth  is  well  opened,  and  the 
tongue  held  by  means  of  the  depressor  mentioned  above. 
The  surgeon  should  be  careful  in  placing  the  tongue  depres- 
sor, so  that  he  may  not  cause  undue  pressure,  which  will  pro- 
duce gagging,  and  prevent  all  further  manipulations.  The 
light  is  then  turned  upon  the  pharynx  by  the  head  mirror,  so 
that  it  is  accurately  focused,  when  the  parts  will  be  well 
illuminated. 

Having  secured  a  good  view  of  the  pharynx,  uvula,  and 
tonsils,  the  throat  mirror  is  to  be  intro-  fig.  19. 

duced.     This  instrument  is  first  warmed 
by  holding  it  for  an  instant  over  the 
flame   of  the   lamp;    its   heat  is   then 
tested  by  placing  it  on  the  back  of  the 
head,  after  which  it  is  gently  and  quick- 
ly introduced,  with  its   reflecting   face 
upwards,  into   the  space   between  the 
soft  palate  and  cavity  of  the  posterior 
pharyngeal  wall.     There  are  some  pa-     Anterior  wares  speculum. 
tients,  however,  in  whom  it  will  be  impossible  to  make  a  rhi- 
noscopic  examination,  on  account  of  the  small  space  between 
the  uvula  and  posterior  wall  of  the  pharynx.    A  very  few,  alio, 


92  BHINOSCOPY. 

have  such  irritable  throats  as  also  to  render  such  an  examina- 
tion impracticable. 

The  examination  of  the  nostrils  anteriorly — anterior  rhinos- 
copy, as  it  is  called  by  Cohen- — is  often  an  important  part  of 
the  examination  of  a  case  of  aural  disease. 

It  is  very  often  sufficient  to  place  the  patient  in  front  of  a 
good  light,  and  open  the  nares  by  pressing  upon  the  tip  of  the 
nose.  If  an  instrument  be  necessary,  I  find  that  the  one  fig- 
ured on  the  preceding  page  serves  a  very  useful  purpose.  I  am 
sorry  that  I  do  not  know  the  name  of  the  inventor  of  this  little 
instrument. 

EXAMINATION  OF  EUSTACHIAN  TUBE. 

~We  may  now  turn,  as  the  next  step  in  our  examination  of 

a  case  of  supposed  aural  disease,  to  the  investigation  of  the 

condition  of  the  Eustachian  tube  and  cavity  of  the  tympanum. 

The  means  of  this  examination  may  be  classified  as  follows  : 

I.  The  Eustachian  catheter. 

II.  Politzer's  method. 

III.  Valsalva's  method. 

IV.  Eustachian  bougies. 

From  the  date  of  the  promulgation  of  the  use  of  the  Eus- 
tachian catheter  by  the  postmaster  of  Versailles,  Guyot,  until 
Toynbee's  time,  the  views  of  the  profession  as  regards  the  use 
of  this  instrument  have  varied  exceedingly.  At  one  time  it 
was  almost  utterly  rejected  by  the  greater  number  of  respect- 
able practitioners,  and  at  another  time  has  been  considered 
by  them  as  a  panacea  in  the  treatment  of  aural  disease.  The 
text-books  of  Wilde  and  Toynbee,  which  attached  very  little 
importance  to  the  use  of  the  Eustachian  catheter,  and  which 
bear  intrinsic  evidence  that  the  authors  did  not  choose  to  be 
very  familiar  with  the  details  of  the  proper  employment  of  the 
instrument,  probably  did  more  than  anything  else  to  cause  the 
profession  in  our  own  country  to  settle  down,  until  a  few  years 
since,  into  the  belief  that  the  Eustachian  catheter  was  always 
a  useless  and  sometimes  a  dangerous  instrument.  I  well  re- 
member the  discouraging  response  of  a  prominent  American 

*  Diseases  of  the  Throat,  p.  75. 


INTRODUCTION  OP  EUSTACHIAN  CATHETER.         93 

practitioner,  who  had  then  had  large  experience  in  aural  dis- 
ease, to  my  statement,  at  the  beginning  of  my  active  profes- 
sional life,  that  I  proposed  to  use  the  Eustachian  catheter  in 
the  treatment  of  diseases  of  the  ear,  that  he  was  glad  to  say 
that  he  never  had  used  the  instrument,  and  this  was  the  com- 
mon sentiment  among  our  respectable  practitioners  until  a  very 
recent  date.  In  regard  to  the  change  in  sentiment  in  this 
regard,  I  only  need  to  say,  that  nearly  every  American  surgeon 
who  now  treats  aural  disease,  attaches  much  importance  to  the 
use  of  this  instrument. 

We  have  now  to  speak  of  the  Eustachian  catheter  as  a 
means  of  diagnosis. 

The  material  of  which  the  instrument  should  be  made  may 
be  either  alloyed  silver  or  hard  rubber.  For  diagnosis  the 
silver  catheter  is  to  be  preferred ;  for  the  injection  of  warm 
vapors,  the  hard  rubber  instrument  is  the  only  one  to  be  used, 
because  the  heat  will  very  soon  make  it  impossible  for  a 
patient  to  bear  the  metal  instrument  in  the  nostril. 

In  the  method  of  introduction,  we  proceed  as  did  Archi- 
bald Cleland,  an  English  surgeon,  who,  after  Guyot,  did  the 
most  to  demonstrate  the  utility  of  entering  the  mouth  of  the 
Eustachian  tube  with  an  instrument,  and  we  pass  the  catheter 
through  the  nostril.  It  is  very  difficult  to  imagine  how  the 
Versailles  layman  succeeded  in  introducing  an  instrument  into 
the  tube,  through  the  mouth.  He  certainly  did  not  use  a 
catheter  such  as  we  now  employ,  and  which  is  sketched  on 
the  next  page.  It  is  a  delicate  tube  of  about  six  inches  in 
length,  with  a  slight  curve  at  its  extremity.  A  long  and  flexi- 
ble catheter  might,  it  is  true,  be  passed  behind  the  soft  palate 
into  or  opposite  the  mouth  of  the  tube,  and  this  is  the  opera- 
tion which  Guyot  demonstrated  to  the  Paris  Academicians, 
and  which,  by  removing  mucus  from  about  the  trumpet-shaped 
pharyngeal  extremity  of  the  canal,  relieved  his  impairment  of 
hearing.* 

The  various  steps  in  the  operation  of  introducing  the  Eus- 
tachian catheter  are  as  follows  : 

1.  Let  the  patient  be  seated  on  a  chair,  with  a  little  higher 
back  than  usual,  so  that  the  head  may  be  supported.     If  the 

*  For  a  fuller  account  of  Gcuyot's  operation,  see  Introductory  Chapter. 


94 


INTRODUCTION  OF  EUSTACHIAN  CATHETER. 


Fig.  20. 


Eustachian  Catheters, 
actual  size. 


patient  be  a  child,  it  can  rest  its  head 
against  a  table  or  wall,  or  what  is  better, 
be  supported  by  an  adult. 

I  seldom  use  the  Eustachian  catheter  in  young 
children  ;  for  them  I  prefer  Politzer's  method  of  in- 
flating the  middle  ear. 

2.  Let  the  patient  blow  his  nose,  so  as 
to  moisten  the  passage  and  remove  any 
collections  of  mucus,  while  the  surgeon 
takes  the  catheter  thoroughly  cleansed 
and  warmed,  and  forces  air  through  it  in 
order  to  be  sure  that  it  is  permeable. 

3.  The  operator,  standing  a  little  to 
one  side,  draws  down  the  upper  lip  with 
the  left  hand,  and  with  the  thumb  and 
finger  of  his  right  hand  lightly  holds  the 
catheter  close  to  the  funnel-shaped  end, 
nearly  in  a  vertical  position,  with  the  ring 
looking  towards  the  median  line  of  the 
body,  until  it  has  entered  the  meatus, 
when  it  is  quickly  turned  to  an  approach 
to  the  horizontal  position,  so  that  the 
beak  rests  on  the  floor  of  the  nasal  mea- 
tus, close  to  the  septum,  with  its  convexity 
upwards. 

4.  The  catheter  is  then  to  be  slid  or  in- 
sinuated backwards  with  a  gentle  motion, 
keeping  it  as  close  as  possible  to  the  floor 
of  the  meatus,  gradually  elevating  the  han- 
dle until  the  instrument  becomes  perfectly 
horizontal  and  the  beak  rests  upon  the 
posterior  wall  of  the  pharynx. 

5.  At  this  point  the  funnel-shaped  end 
of  the  catheter  in  the  hand  of  the  operator 
is  to  be  raised  a  little  above  the  horizontal 
line  and  at  the  same  time  withdrawn  a 
little. 

6.  Turn  the  catheter  about  a  quarter  on 
its  axis,  from  within  outwards.     This  mo- 


INTEODUCTION   OF  EUSTACHIAN   CATHETER. 


95 


tion  lifts  the  beak  of  the  instrument  into  the  mouth  of  the 
Eustachian  tube.     This  latter  movement  is  aided  somewhat 


Fig.  21. 


Introduction  of  Eustachian  Catheter. 

by  the  contraction  of  the  soft  palate,  which  performs  a  swal- 
lowing movement,  raises  itself,  and  lifts  the  beak  of  the  instru- 
ment into  the  tube.  Once  in  position  the  catheter  should  not 
cause  the  patient  any  inconvenience  in  speaking  or  swallowing. 

The  difficulties  that  are  found  in  introducing  the  catheter, 
simple  manipulation  as  it  is,  arise  from  two  causes  : 

First,  the  surgeon  does  not  always  hold  the  instrument  in 
a  vertical  position  (see  Fig.  21)  until  he  has  got  the  beak  well 
into  the  meatus.  A  failure  to  do  this  will  often  cause  the  instru- 
ment to  pass  between  the  inferior  and  middle  turbinated  bones, 
instead  of  along  the  floor  of  the  meatus,  which  must  be  hugged 
in  order  that  the  instrument  may  get  to  the  mouth  of  the  tube. 


96 


INTEODUCTION   OF  EUSTACHIAN   CATHETEE. 


Second,  the  patient  is  apt  to  shut  his  eyes  spasmodically 
and  contract  his  facial  muscles,  and  thus  prevent  the  relaxa- 


FiG.  22. 


The  Eustachian  Catheter  in  Position. 

tion  of  the  parts  that  is  necessary  during  the  manipulation. 

This  difficulty  is  only  to  be  overcome  by  persuading  the  pa- 
fig.  23.  tient  to  open  his  eyes  and  look  about  the  room, 

which  can  be  done  if  the  surgeon  have  a  quiet, 
assuring  manner.  This  difficulty  usually  passes 
away  with  the  second  or  third  use  of  the  instru- 
ment, and  sometimes  it  does  not  arise. 

Having  introduced  the  catheter  we  may 
force  air  through  it  into  the  cavity  of  the  tym- 
panum, by  means  of  an  air-bag  whose  nozzle 
should  fit  accurately  into  the  funnel-shaped  ex- 
tremity of  the  nasal  instrument.  Air  may  also 
be  blown  in  from  the  lungs  of  the  examiner 
through  a  slender  bit  of  rubber  tubing,  the  tips 


DIAGNOSTIC  TUBE. 


97 


of  which  are  placed  in  the  opening  of  the  catheter  and  the 
mouth  of  the  examiner  respectively.  The  use  of  the  rubber 
bag  or  syringe  is  to  be  preferred  to  this  method  as  being  a 
more  cleanly  and  delicate  one. 

After  air  has  been  forced  into  the  middle  ear  in  this  man- 
ner, the  membrana  tympani  should  again  be  examined  by  the 
surgeon,  to  determine  if  it  has  become  injected,  or  if  it  has 
undergone  any  change  in  position ;  that  is  to  say,  he  should 
see  whether  the  current  has  actually  reached  the  cavity  of  the 
tympanum  or  not. 

Most  authorities  recommend  the  use  of  an  instrument  like 
the  stethoscope,  which  is  placed  in  the  ear  of  the  patient 
while  the  air  is  being  driven  through  the  tube,  and  they  claim 
to  be  generally  able  to  decide  as  to  whether  the  air  enters  by 
the  sound  communicated  through  the  tube.  I  am  constrained 
to  think  that  it  is  very  difficult  to  distinguish  sounds  proceed- 
ing from  the  pharyngeal  mouth  of  the  tube  from  those  pro- 
duced in  the  cavity  of  the  tympanum,  and  I  do  not,  therefore, 
attach  that  importance  to  the  use  of  the  stethoscope  in  this 
manner,  that  has  been  usually  ascribed  to  it ;  but  I  rely  more 
upon  the  appearances  of  the  membrane  of  the  tympanum  after 


Fig.  24. 


Diagnostie  Tube. 


the  air  has  been  forced  in,  with  some  attention  also  to  the 
sensations  of  the  patient,  as  to  where  the  air  is  felt,  than  upon 
the  use  of  the  so-called  otoscope— although  I  would  be  very 


98  DIAGNOSTIC   TUBE. 

far  from  wholly  rejecting  its  employment,  or  from  denying 
its  value. 

The  otoscope  consists  essentially  of  a  piece  of  elastic 
tubing  with  a  tip  on  each  end,  designed  for  the  ear  of  the 
patient  and  that  of  the  examiner  respectively.  It  should  not 
be  called  an  otoscope,  but  rather,  as  Kramer  suggests,  the 
diagnostic  tube.  The  mirror  for  examining  the  ear  should  be 
called  the  otoscope,  just  as  that  for  examining  the  fundus  of 
the  eye  is  named  the  ophthalmoscope ;  that  for  the  throat,  the 
laryngoscope,  and  so  on. 

POLITZER'S  METHOD  OF  INFLATING  THE  EAE. 

The  next  means  of  examining  the  condition  of  the  Eusta- 
chian tube  and  cavity  of  the  tympanum  is  named,  from  the 
gentleman  who  suggested  it,  Politzer's  method.  It  is  a  means 
of  diagnosis  and  treatment  of  very  great  value,  and  we  owe 
very  much  to  Dr.  Adam  Politzer,  of  Yienna,  for  this  method 
of  sending  air  into  the  middle  ear. 

As  is  very  well  known,  in  the  action  of  swallowing,  the 
uvula  rests  upon  the  pharyngeal  wall  so  as  to  shut  off  the 
upper  from  the  lower  pharyngeal  space ;  so  that  persons 
affected  with  cleft  palate,  who  cannot  thus  separate  these 
spaces,  are  greatly  inconvenienced  by  the  passage  of  solids 
and  fluids  upwards  to  the  posterior  nares.  It  was  long  ago 
shown  that  the  pharyngeal  orifice  of  the  Eustachian  tube 
opened  during  the  swallowing  process.  Politzer's  method 
takes  advantage  of  these  physiological  facts  in  the  following 
way :  the  person  to  be  examined  takes  a  little  water  in  the 
mouth,  while  the  surgeon  places  an  air-bag,  with  an  appro- 
priate nozzle,  into  one  of  the  nostrils,  closes  the  other  with  his 
finger,  and  causes  the  patient  to  swallow  the  water  at  a  given 
signal  previously  agreed  upon,  when  he  forces  in  the  air  by 
compressing  the  india-rubber  bag.  I  usually  say  "now"; 
upon  which  the  patient  swallows. 

In  examining  children,  I  use,  as  suggested  by  Mr.  Hinton, 
a  piece  of  rubber  tubing,  and  force  the  air  from  my  own  lungs, 
on  giving  a  signal  by  raising  the  hand. 

The  effect  of  the  air  thus  forced  in  upon  the  membrana 


POLITZER  S   METHOD. 


99 


tympani  is  often  almost  wonderful.  A  person  who  has  be- 
come deaf  to  ordinary  conversation  sometimes  in  an  instant 
again  hears  the  familiar  tones  of  human  conversation,  and 
feels  himself  in  a  new  world.  In  such  a  case,  mucus  has  usu- 
ally obstructed  the  calibre  of  the  tube,  and  is  driven  away  by 
the  current  of  air,  which  must  of  necessity  go  against  the 

Fig.  25. 


Method  of  Using  Politzer's  Apparatus.    {With  Inhaler  Attachment.) 


mouths  of  the  tube,  and  will  usually  pass  on  into  the  middle 
ear.  The  patient's  own  testimony  will  usually,  although  not 
always,  be  conclusive  as  to  whether  the  air  entered  the  ear. 
The  exceptional  cases  are  those  in  which  the  Eustachian  tube 
and  the  cavity  of  the  tympanum  have  become  so  narrowed  .by 
a  hypertrophy  and  sclerosis  of  the  lining  mucous  membrane 
that  only  a' very  narrow,  feeble  current  can  enter.  We  shall 
have  Deed  to  dwell  upon  the  uses  of  Politzer's  method  when 


100  valsalva's  method. 

we  are  discussing  the  affections  of  the  middle  ear,  and  I  there- 
fore content  myself  with  this  description  of  it,  while  we  pass 
on  to  Valsalva's  method  of  inflating  the  ear. 


VALSALVA'S  METHOD. 

The  distinguished  anatomist  Valsalva,  who  is  well  known 
to  the  profession  by  his  treatise  on  the  ear,  suggested  a  means 
of  inflating  the  membrana  tympani,  which  has  become  so 
popular  as  to  be  used  by  nearly  two-thirds  of  all  the  patients 
who  come  to  physicians  on  account  of  their  ears.  It  has  been 
recommended  by  generations  of  medical  men  as  a  means  of 
curing  affections  of  the  ear,  or  of  determining  if  the  Eustachian 
tube  be  open,  or  the  drum-head  broken.  Universal  as  is  its 
use,  I  regard  it  as  almost  a  useless  and  not  an  entirely  safe 
method.  It  consists  essentially  in  forcing  air  into  the  ear, 
after  a  vigorous  inspiration,  the  mouth  and  ndftrils  being 
closed.  It  will  be  observed  that  when  the  ear  is  inflated  by 
this  method,  a  very  great  use  of  the  muscles  of  the  chest 
is  made  ;  and  just  in  this  lies  the  danger  to  the  ear.  This 
vigorous  expansion  of  the  chest  causes  a  congestion  of  the 
ear  which  is  sometimes  more  or  less  permanent,  and  materially 
harms  the  part  by  increasing  the  flow  of  blood  to  it.  There 
is  another  objection  to  the  frequent  employment  of  the  Val- 
salvian  method,  or  experiment,  as  it  is  sometimes  styled.  It 
soon  ceases  to  have  its  momentary  effect  of  increasing  the 
hearing  distance,  which  it  does  by  rendering  the  membrane  of 
the  drum  tenser,  and  then  the  membrane  becomes  relaxed  and 
flaccid,  so  that  I  have  sometimes  seeu  the  membrana  tympani 
of  patients  who  have  been  in  the  daily  and  perhaps  hourly 
habit  of  forcing  air  into  the  ears,  flap  to  and  fro  like  a  valve 
on  the  slightest  movements  of  the  nostrils. 

This  latter  objection,  of  course,  applies  to  Politzer's  method 
if  it  be  very  frequently  practised  ;  but  as  it  must  be  done  by 
means  of  an  apparatus,  patients  are  not  so  apt  to  take  it  into 
their  own  hands. 

I  do  not  now  advise  the  use  of  the  Valsalvian  method  in 
the  treatment  of  aural  disease,  and  as  a  means  of  diagnosis  it 


BOUGIES.  101 

is,  in  most  cases,  vastly  inferior  to  the  use  of  the  catheter  or 
Politzer's  method. 

I  may  add  a  word  about  the  last-named  means  of  examining 
the  Eustachian  tube,  namely,  bougies.  Filiform  catgut  bougies 
may  sometimes  be  employed  with  advantage  in  determining  if 
the  non-entrance  of  air  by  the  catheter  or  Politzer's  method  be 
due  to  a  stricture ;  but  the  need  for  their  employment  occurs 
only  in  a  very  limited  number  of  cases,  and  when  they  are 
used  great  care  and  judgment  are  necessary.  This  subject 
will  be  fully  discussed  in  the  chapter  on  Chronic  Non-suppu- 
rative  Inflammation  of  the  Middle  Ear. 

It  will  be  understood  by  the  reader  that  very  many  cases 
of  aural  disease — for  example,  those  of  the  external  auditory 
canal — will  not  require  the  exhaustive  examination  that  has 
just  been  detailed,  yet  many  cases  will  require  a  systematic  and 
complete  observation,  such  as  I  have  attempted  to  delineate, 
in  order  to  a  diagnosis  which  shall  be  exact  and  consequently 
valuable.  The  time  thus  consumed  is  sometimes  considerable, 
but  not  as  great  in  amount  as  those  who  simply  read  these 
descriptions  will  perhaps  imagine.  The  details  occupy  more 
in  description  than  in  execution  ;  and  their  strict  performance 
will  of  themselves  in  time  make  those  who  carry  them  out  good 
observers  of  the  phenomena  of  disease. 


CHAPTER    IV. 

THE  DISEASES  OF  THE  AURICLE. 

A  finely  formed  auricle  is  justly  esteemed  one  of  the  marks 
of  personal  beauty.  The  celebrated  physiognomist,  Lavater, 
also  attached  considerable  importance  to  this  part  in  deter- 
mining character.  A  humorous  German  critic,  quoted  by  Yol- 
tolini,  in  speaking  of  Lavater's  ideas  of  physiognomy,  says : 
"It  would  be  very  queer  of  Dame  Nature,  if  she  had  hung  every 
one's  character  on  the  nose,  so  that  any  one  who  was  a  mas- 
ter in  physiognomy  could  read  it.  Perhaps  fearing  this,  some 
people  shut  their  eyes  and  are  ashamed  to  look  one  in  the 
face."  A  French  author,  Dr.  Amedee  Joux,  quoted  by  Yon 
Troltsch,  goes  much  farther  than  Lavater  in  his  estimation  of 
the  signification  of  the  auricle  ;  and  besides  the  part  which  it 
plays  in  indicating  human  character,  he  claims  that,  more 
than  any  other  organ  of  the  body,  it  descends  with  its  par- 
ticular form  from  father  to  child,  and  that  by  the  shape  of 
the  auricle  we  may  be  assisted  in  determining  the  legitimacy 
of  children,  and  the  conjugal  fidelity  of  a  mother.  He  says, 
"  Montre-moi  ton  oreille,je  ne  dirai  qui  ton  es,  ok  tu  viens,  et  ou  tu 
vas,"  or,  as  we  should  say  in  English,  "  Let  me  see  your  ear, 
and  I  will  tell  you  who  you  are,  where  you  came  from,  and 
where  you  are  going." 

I  am  inclined  to  think  that  this  view  of  the  importance  of 
the  auricle  is  Gallic,  rather  than  truly  physiological.  Eecent 
authorities,  such  as  Gruber  of  Vienna,  believe  that  the  grace 
and  beauty  of  the  auricle  have  little  influence  upon  the  func- 
tions, whatever  may  be  the  physiognomic  or  other  significance 
of  the  part.     It  makes  very  little  difference  as  regards  the 

*  Diseases  of  the  Ear.    2d  American  Edition,  p.  14. 


FUNCTIONS  OF  THE  AUBICLE.  103 

bearing  power,  however  much.it  may  affect  personal  beauty, 
whether  the  auricle  lies  exactly  at  a  proper  and  graceful  angle 
on  the  head,  or  whether  it  be  closely  adherent,  and  thus  sim- 
ply form  an  ugly  appendage ;  and  yet  the  auricle  has  func- 
tions, although,  like  the  muscles  which  move  it,  these  functions 
in  man  are  comparatively  unimportant  and  rudimentary.  We 
all  know,  however,  that  there  is  some  importance  attached  to 
this  part  by  persons  with  impaired  hearing ;  for  all  of  us  have 
seen  such  persons  place  the  hand  behind  the  auricle  when  lis- 
tening intently,  in  order  to  facilitate  the  conduction  of  sound 
into  the  auditory  canal. 

Voltolini*  considers  the  auricle  to  be  a  reflector,  con- 
denser, and  conductor  of  the  waves  of  sound.  As  a  reflector, 
the  fossa  of  the  concha  throws  the  sound-waves  against  the 
tragus,  whence  they  pass  into  the  auditory  canal.  This  author 
is  inclined  to  the  belief  that  when  the  auricle  is  small 
the  concha  is  deeper,  in  order  to  compensate  for  the  loss. 
The  auricle  is  a  condenser  of  sound,  just  as  is  every  other 
firm  and  elastic  body.  Its  chief  function,  however,  accord- 
ing to  Yoltolini,  is  that  of  a  conductor  of  sound.  If  it  were 
merely  a  reflector  and  condenser,  it  would  have  done  its 
work  better  if  formed  of  bone.  It  is  to  be  considered  as  an 
external  membrana  tympani.  This  outer  membrane  is  placed 
in  different  degrees  of  tension  by  reflex  action,  just  as  is  the 
true  membrana  tympani  by  the  tensor  tympani  muscle.  This 
may  be  illustrated  by  observing  the  operation  of  syringing  the 
ear.  At  the  entrance  of  each  stream  of  water,  the  auricle 
moves,  and  at  times  this  motion  is  sufficient  to  cause  a  back- 
ward current  of  the  water  from  the  ear.  Again,  many  persons 
with  impaired  hearing  can  hear  the  watch,  if  it  touch  but  the 
outermost  tip  of  the  auricle,  while  it  cannot  be  heard  if  held 
but  a  line  removed  from  the  part. 

Yoltolini  sums  up  his  consideration  of  the  auricle,  by  say- 
ing that  "  the  auricle  may  be  considered  as  the  outer  orifice 
of  a  hearing  or  speaking-tube,  of  which  the  external  auditory 
canal  is  the  tube  proper — and  since  the  sound  receiver  is  so 
large  in  proportion  to  the  calibre  and  length  of  the  tube  we 

*  Monatsschrift  fur  Ohrenheilkende,  Jahrgang  II,  No.  I. 


104  MALFOEMATIONS. 

may  see  what  nonsense  it  is  to  recommend  the  so-called  invisi- 
ble ear-trumpets,  which  are  simply  short  aural  specula." 

A  full  consideration  of  the  affections  of  the  auricle  belongs 
rather  to  general  than  to  special  surgery,  inasmuch  as  dis- 
eases of  the  auricle  rarely  cause  marked  impairment  of  the 
hearing  ;  and  yet,  for  the  sake  of  completeness  in  this  work,  I 
may  call  attention  to  the  principal  symptoms,  with  the  general 
pathology  and  treatment  of  malformations  and  acquired  affec- 
tions of  this  part.  "We  may  conveniently  classify  them  as 
follows : 

I. — Malformations. 
II.' — Tumors. 
III. — Malignant  disease. 
IV. — Injuries. 
Y. — Eczema. 

MALFOEMATIONS. 

Many  of  the  so-called  malformations  are  the  simple  results 
of  ill  treatment  of  the  auricle.  Many  women  cover  their  ears 
so  tightly  with  their  hair,  cap,  and  hood,  as  finally,  by  the 
excessive  pressure,  to  obliterate  the  natural  ridges  and  depres- 
sions which  go  to  make  up  a  finely  shaped  ear.  Boys  often 
get  into  the  bad  habit  of  pressing  their  caps  down  upon  their 
ears.  They  thus  cause  them  to  lap  over,  and  give  them  the 
unsightly  appearance  known  as  "  dog  ears." 

All  the  attention  which  we  as  medical  advisers  may  give 
to  such  acquired  malformations,  is  to  warn  those  who  thus 
improperly  treat  this  appendage  of  the  risk  they  are  running 
of  becoming  deformed. 

There  is  a  class  of  malformations  of  the  auricle  which  has 
the  same  pathological  interest  with  other  forms  of  arrested  de- 
velopment, such  as  spina  bifida,  coloboma  iridis,  etc.,  but  unfor- 
tunately they  are  also  cases  for  which  our  art  can  do  nothing. 
I  refer  to  those  cases  in  which  the  auricle  is  congenitally 
absent,  or  where  it  exists  only  in  a  rudimentary  form.  In 
such  instances  the  middle  and  internal  ear  are  usually  also  in 
a  deficient  condition,  and  the  auditory  canal  closed.     Cases 


MALFORMATIONS.  105 

have  been  seen,  however,  where  the  auricle  was  absent,  while 
the  other  parts  of  the  ear  were  in  a  normal  condition,  and  in 
which  there  was  a  good  hearing  power.  The  description  of  a 
case  recently  reported  by  Dr.  Knapp,  of  New  York,  will  serve 
as  a  description  for  the  whole  class  :* 

"In  a  healthy  child  of  three  months,  the  left  auricle  con- 
sisted of  a  slightly  tortuous  ridge,  two  lines  in  height  and 
three-quarters  of  an  inch  in  length.  It  felt  tough  to  the  touch, 
like  a  healthy  auricle,  being  undoubtedly  composed  of  carti- 
lage and  skin.  Its  shape  represented  the  rudiments  of  the 
helix  and  lobule ;  the  other  parts  of  the  auricle  were  not 
visible.  Immediately  in  front  of  the  middle  of  the  rudimen- 
tary auricle,  there  was  a  small  round  depression,  indicating 
the  situation  of  the  external  meatus."  An  incision  through 
this  point  showed  that  the  auditory  canal  was  filled  up  by 
bone,  or  rather  that  there  was  no  canal. 

The  experience  of  the  profession  is  against  the  attempt  to 
open  a  canal  to  an  organ  which  will  probably  be  found  so  im- 
perfect that  sound  cannot  be  perceived  by  it.  By  means  of 
the  tuning-fork  we  may  always  determine  in  the  case  of  any 
persons  of  sufficient  age  whether  the  central  apparatus  be  or 
be  not  unimpaired.  If  the  canal  be  closed,  while  the  laby- 
rinth is  intact,  the  vibrations  of  a  tuning-fork  whose  handle  is 
placed  on  the  teeth  or  forehead  will  be  heard  more  distinctly 
in  the  affected  than  in  the  sound  ear.  The  reflection  of  the 
so  and  waves  is  diminished  by  the  stoppage  of  the  auditory 
passage,  just  as  in  cases  of  inspissated  cerumen  and  thicken- 
ing of  the  mucus  membrane  of  the  cavity  of  the  tympanum 
and  the  Eustachian  tube,  or  perhaps  there  is  no  nervous  appa- 
ratus on  that  side  to  receive  the  sound  waves. 

Superfluous  auricles  sometimes  occur,  just  as  do  supernume- 
rary toes  and  fingers.  They  are  objects  of  anatomical  curiosity 
rather  than  of  therapeutical  interest.  Beck  f  details  a  num- 
ber of  cases  in  which,  by  freaks  of  Nature,  the  auricle  was 
placed  on  the  back,  the  shoulder,  and  near  the  angle  of  the 
mouth. 

*  Transactions  American  Otological  Society,  p.  14.    3d  Tear. 
•f-  Krankheiten  des  Gfehororgans,  p.  108. 


106  TUMOES  OF  THE  AURICLE. 

The  tumors  found  in  the  auricle  may  be  divided  into  the 
following  classes  : 

I. — Fibro-cartilaginous. 
II. — Sebaceous. 
III. — Vascular. 

FIBKO-CABTILAGINOUS  TUMOES. 

The  first-named  form  is  a  simple  hypertrophy  of  the  nor- 
mal structure  of  the  auricle. 

According  to  Billroth,*  these  tumors  consist  chiefly  of  fusi- 
form cells  and  connective  tissue,  and  are  nothing  more  than 
hypertrophy  of  a  cicatrix  such  as  occurs  on  other  parts  of  the 
body  after  injuries. 

They  seem  to  occur  much  more  frequently  among  the 
African  than  the  Caucasian  race.  I  have  removed  several  of 
these  growths  from  the  auricles  of  negro  women,  while  I  have 
but  rarely  seen  them  among  whites.  I  am  also  informed  that 
they  occur  very  frequently  among  the  Africans  of  the  East 
and  West  Indies,  where  they  grow  to  an  enormous  size. 

The  etiology  of  these  growths  is  very  simple,  if  my  own 
experience  may  be  trusted  on  this  point.  They  occur  as  the 
result  of  the  irritation  of  the  lobes  produced  by  the  truly 
barbarous  custom  of  piercing  the  ears  in  order  that  ear-rings 
may  be  worn.  They  are  much  more  apt  to  be  found  in  the 
lower  classes,  because  these  use  brass  ear-rings  much  more 
commonly  than  wealthier  persons,  although  the  growths  may 
occur  even  if  gold  ear-rings  are  used.  They  sometimes  reach 
an  enormous  size,  and  become  a  very  serious  deformity.  If 
these  ornaments  are  considered  indispensable,  as  no  doubt 
they  are,  ladies  should  wear  them  by  causing  them  to  be 
clasped  around  the  auricle  by  means  of  a  suitable  contrivance 
now  sold  by  the  jewellers  and  very  much  used. 

One  of  the  older  authors,  Frank,  gives  illustrations  of  the 
proper  instruments  with  which  to  pierce  the  ears,  with  a  de- 
tailed account  of  the  operation ;  but  the  efforts  of  the  medical 
adviser  should  be  towards  the  prevention  of  the  barbarous 
custom  rather  than  increasing  the  facilities  for  retaining  it. 

*  General  Surgical  Pathology  and  Therapeutics,  p.  551.  Translated  by 
C.  E.  Hackley,  M.D. 


OTH^MATOMATA.  107 

Fibrocartilaginous  tumors  should  be  removed  if  they 
attain  such  a  size  as  to  be  at  all  troublesome.  The  removal 
is  readily  effected  by  a  V-shaped  incision  made  with  strong 
scissors.  The  edges  of  the  wound  are  then  brought  together 
by  sutures.  The  resulting  deformity  is  usually  very  slight, 
and  is  much  less  than  that  from  the  tumor. 

Sebaceous  tumors  should  be  removed  by  enucleation. 
Erectile  tumors  occurring  on  the  auricle  are,  perhaps,  best 
treated  by  means  of  the  galvano-caustic  apparatus,  of  which 
more  will  be  said  when  we  come  to  the  subject  of  aural  polypi. 

OTELEMATOMATA,  OK  VASCULAR  TUMOR  OF  THE  EAR. 

The  peculiar  effusion  of  blood  which  quite  often  occurs  in 
the  auricle,  and  especially  among  the  insane,  and  which  is 
known  as  othaematoma,  hematoma  auris,  or  vascular  tumor 
of  the  auricle,  has  caused  quite  an  amount  of  discussion 
among  scientific  observers.  Yirchow*  and  E.  E.  Hun,t  of 
Albany,  N.  Y.,  are  the  authors  who  seem  to  me  to  have 
given  us  the  clearest  and  best  accounts  of  this  interesting 
affection,  and,  in  what  I  am  about  to  say,  I  shall  avail  myself 
of  their  labors,  together  with  some  experience  of  my  own  on 
this  subject. 

The  so-called  othsematomata  may  be  divided  into  those  of 
idiopathic  and  traumatic  origin.  The  idiopathic  form  occurs 
chiefly,  though  not  exclusively,  among  the  insane.  I  have 
seen  two  cases  occurring  in  people  of  sound  mind,  which  cor- 
responded very  well  with  the  descriptions  of  those  occurring  in 
the  insane  as  given  by  Dr.  Hun,  whose  observations  seem 
to  have  been  confined  to  this  class.  My  friend,  Dr.  E.  G. 
Loring,  has  also  seen  one  idiopathic  case  in  a  sane  person. 
The  symptoms  of  the  idiopathic  form  of  the  affection  are  as 
follows  :  Before  the  tumor  appears  we  find  the  ear  or  ears,  as 
the  case  may  be,  red  and  swollen,  and  the  face  and  eyes  give 
evidence  of  a  strong  determination  of  blood  ;  occasionally, 
however,  there  is  no  redness  of  the  skin,  and  there  is  merely 
some  oedema  of  the  auricle  ;  among  the  insane  there  is  no 

*  Die  Krankhaften  Gescliwulsten,  Bd.  I,  p.  135. 
t  American  Journal  of  Insanity,  July,  1870. 


10S  OTR2EMATOMATA. 

manifestation  of  general  ill  health.  In  a  few  hours,  or  it  may 
be  days,  an  effusion  of  blood  takes  place.  The  tumor  occu- 
pies the  concha  in  the  main,  but  it  extends  over  the  auricle  so 
as  to  obliterate  its  ridges  and  cause  the  usually  beautiful  part 
to  appear  like  a  roundish  reddened  tumor,  varying  in  size 
from  a  bean  to  a  hen's  egg.  This  tumor  is  evidently  of  an 
inflammatory  nature,  being  hot  and  painful.  The  swelling  is 
usually  quite  firm,  but  a  careful  examination  will  detect 
fluctuation. 

The  vascular  tumor  of  the  auricle,  judging  from  Dr.  Hun's 
statistics,  is  much  more  common  among  men  than  women. 
He  reports  twenty-four  cases,  of  which  twenty-three  occurred 
in  males.  The  form  of  insanity  was  general  paresis  in  eight 
cases,  melancholia  in  six,  acute  mania  in  four,  chronic  mania 
in  four,  and  dementia  in  two.  These  statements  accord  with 
the  views  of  other  authors,  so  that  we  may  conclude  that 
hsematoma  auris,  when  occurring  in  the  insane,  is  a  symptom 
which  is  highly  unfavorable,  and  which  points  to  an  incurable 
form  of  disease  of  the  brain. 

The  tumor  either  ruptures  spontaneously,  sometimes  with 
such  violence  as  to  spirt  the  blood  to  a  distance  of  several 
feet,  or,  unless  interfered  with,  is  gradually  absorbed.  Spon- 
taneous rupture  is  more  common  than  absorption. 

Dr.  Hun's  observations  show  that  the  traumatic  and  idio- 
pathic othsematornata  are  not  alike  ;  for  in  one  case  which  he 
details,  an  insane  person,  already  suffering  from  hgematoma  of 
one  auricle,  received  a  blow  from  a  broom-handle  on  the  other, 
which  produced  swelling  and  ecchymosis,  but  no  hematoma.  We 
must,  therefore,  I  think,  strictly  distinguish  the  idiopathic 
from  the  traumatic  form. 

The  etiology  of  hsematoma  is  deemed  by  Hun  to  be  two- 
fold, viz.,  cerebral  congestion  and  centripetal  irritation  of  the 
system  by  the  emotions ;  and  he  considers  either  of  these 
causes  sufficient  to  produce  the  effusion.  In  general  paresis 
there  is,  according  to  all  authors,  a  tendency  to  repeated  con- 
gestions of  the  head,  and  it  is  supposed  that  the  blood-vessels 
of  the  ears  become  so  dilated  as  to  favor  the  effusion.  The 
second  factor  in  producing  hsematoma  auris,  centripetal  irri- 
tation of  the  sympathetic  from  strong  emotions,  is  especially 


OTHiEMATOMATA. 


109 


active  among   the  insane,  because   their  emotions   are  not 
under  the  control  of  the  will. 

Virchow  has  made  the  pathology  of  othsematomata  very 
plain,  both  by  his  descriptions  and  the  excellent  illustrations 
which  he  furnishes  in  his  great  treatise  on  tumors.  He  says  that 
"  the  older  authors  described  the  affection  as  erysipelas  of  the 
auricle  occurring  in  the  insane.  It  was  supposed  that  in  the 
hyperemia  and  general  change  in  the  system  a  hemorrhage 
occurred,  which  caused  a  separation  of  the  perichondrium  from 
the  cartilage  ;  but  in  true  othsematomata,  pieces  of  the  carti- 
lage become  attached  to  the  perichondrium." 


Fig.  26. 


Fig.  27- 


Othatmatoma. 
From  a  Photograph  taken  from  a  plaster 
cast,  when  the  tumefaction  was  great- 
est.   After  Hun. 


The  same  Ear  after  rupture  and  con- 
traction had  taken  place.  After 
Hun. 


Case  I. — J.  A.  C,  set.  34.  General  Paresis.  Admitted  January,  1857.  In- 
sanity hereditary  in  his  family.  Discharged  June,  1858.  Ke-admitted  May, 
1859.  July  24,  a  simple  sanguineous  cyst  was  observed  in  each  ear.  Effusion 
rapidly  took  place  until  the  outlines  of  the  auricle  were  obliterated.  Sept.  30, 
the  tumors  have  gradually  subsided.    Patient  died  May  10,  1860. 

According  to  the  Berlin  pathologist,  the  morbid  process 
seems  to  be  primarily  a  softening  or  deliquescing  one,  induced 
by  general  disturbances  of  nutrition,   or  possibly — although 


110 


OTH.EMATOMATA. 


this  class  of  cases  seems  to  belong  to  itself — by  local  injuries 
of  the  cartilage.  The  tumor  disappears  either  by  gradual 
absorption,  spontaneous  rupture,  or  by  the  puncture  of  the 
surgeon.  Coagula  often  form,  which  make  a  delicate  coating 
over  the  separated  portions,  and  these  afterwards  serve  as 
means  of  adhesion.  "When  suppuration  does  not  take  place, 
great  deformity  is  apt  to  occur  from  the  thickening  and  retrac- 
tion of  the  soft  parts,  especially  of  the  perichondrium. 


Fig.  28. 


Fig.  29. 


Shotting  amount  of  contraction  after 
rupture  of  cyst.    After  Hun. 


Shoivs  separation  of  perichondrium 
from  the  cartilage.  After  Hun. 


Case  II. — D.  M.,  set.  — .  Melancholia.  Second  attack.  Hasmatoma  began 
May  18, 1869.  On  July  3,  had  hematoma  on  both  ears.  Aug.  1,  the  left  auricle 
burst  at  upper  portion  of  concha,  and  the  contents,  consisting  of  fluid  and  clotted 
blood,  were  thrown  to  the  ceiling  a  distance  of  12  feet.  Died  Sept.  9,  1869.  A 
section  of  auricles  showed  that  the  perichondrium  was  much  thickened,  and 
separated  from  the  auricular  cartilage  on  its  outer  aspect,  so  as  to  leave  a  large, 
smooth  cavity,  lined  with  a  smooth,  shining  membrane,  and  containing  a  few 
drops  of  serous  fluid. 

The  authorities  differ  as  to  the  proper  method  of  treating 
idiopathic  othffimatomata.  Dr.  Hun  says  that  puncturing  or 
laying  open  the  sac  does  more  harm  than  good.  He  believes 
that  the  least  amount  of  deformity  is  obtained  when  the  effu- 
sion is  gradually  absorbed.     Dr.  Gray,  of  the  Utica  Insane 


OTHJEMATOMATA.  Ill 

Asylum,  proposes  to  ligate  the  p6sterior  auricular  artery. 
Gruber  advises  the  evacuation  of  the  fluid  and  the  coagula, 
and  the  use  of  a  compressive  bandage.  My  own  limited  expe- 
rience inclines  me  to  Gruber's  method  of  treatment. 

Vascular  tumors  caused  by  violence  should  not  be  con- 
founded with  those  occurring  idiopathic  ally. 

Gudden,  a  German  writer  and  physician  for  the  insane, 
quoted  by  Yirchow,  has  shown  that  the  auricles  of  ancient 
statues  are  very  frequently  ornamented  by  tumors  resembling 
the  vascular  effusions  seen  among  the  insane.  In  the  gallery 
at  Munich  the  head  of  Hercules  has  such  ears.  These  mis- 
shapen auricles  are  the  typical  marks  of  the  ancient  boxers  or 
pugilists.  Such  fighters  wrapped  their  hands  in  leather,  and, 
thus  armed,  struck  the  ears  of  their  antagonists ;  consequently 
in  the  figures  of  Hercules,  Pollux,  and  other  classical  fighters, 
a  deformed  auricle  is  a  regular  appearance.  Other  historical 
personages — the  Trojan  Hector  for  example — are  represented 
as  having  othsematoinata. 

To  conclude  from  these  observations  that  the  othsematom- 
ata  are  aliuays  the  result  of  traumatic  influences,  that  they 
are  more  frequent  among  the  insane  because  they  are  very  apt 
to  injure  themselves  or  be  injured  by  their  attendants,  seems 
to  me  to  be  manifestly  incorrect,  judging  both  from  Dr.  Hun's 
observations  and  from  the  fact  that  these  tumors  are  very 
uncommon.  Even  the  English  writers,  living  in  the  land  pre- 
eminent for  pugilists,  scarcely  mention  them.  Wilde*  describes 
and  gives  an  illustration  of  one  case,  however,  which  seems  to 
have  been  a  hematoma,  but  was  not  recognized  as  such  by 
the  author.  It  was  idiopathic  in  origin.  It  occurred  in  a 
male,  aged  twenty-four,  and  was  about  the  size  of  a  small 
pear.  It  occupied  the  upper  portion  of  the  left  auricle,  be- 
tween the  helix  and  the  concha.  It  was  treated  by  incisions, 
and  considerable  deformity  resulted. 

Toynbee  f  describes  these  cases  under  the  head  of  cysts, 
and  seems  inclined  to  ascribe  a  traumatic  origin  to  them,  and 
he  states  that  it  is  the  opinion  of  Dr.  Thurnam,  physician  to 
one  of  the  County  Insane  Asylums  of  England,  that  they  are 

*  Aural  Surgery,  English  edition,  p.  164. 

f  Diseases  of  the  Ear,  American  edition,  p.  53. 


112  0TH2EMAT0MATA. 

less  frequent  than  formerly,  on  account  of  the  fact  that  vio- 
lence is  not  so  much  employed  in  the  management  of  the 
insane.  Dr.  Thurnam  evacuated  the  contents  of  the  tumors, 
and  used  setons,  and  thus  claims  to  have  prevented  the 
deformity  to  some  extent.  Toynbee  mentions  but  one  case, 
that  of  a  boxer,  that  he  has  himself  seen  ;  but  his  description 
is  not  detailed  enough  to  allow  us  to  judge  whether  it  was 
identical  with  those  observed  in  the  insane. 

Dr.  Hun  is  so  strongly  of  the  opinion  that  the  idiopathic 
othsematoma  are  symptoms  of  insanity,  that  he  would  con- 
sider any  person  having  such  tumor  upon  the  auricle,  even  if 
sane,  as  a  person  to  be  carefully  observed  as  to  cerebral 
symptoms.  This  is  an  opinion  of  Dr.  Hun's  which  the 
author  gained  in  a  recent  conversation  with  him  upon  this 
subject. 

I  have  also  recently  had  a  very  interesting  and  instructive 
interview  with  Dr.  Broion-Sequard,  now  of  this  city,  on  the 
subject  of  the  etiology  of  vascular  tumors  of  the  auricle. 

Dr.  Sequard  has  found  that  sections  of  the  restiform  bodies, 
or  largest  column  of  the  medulla  oblongata,  in  animals  (Guinea 
pigs),  will  produce  a  hemorrhage  beneath  the  skin  of  the  auri- 
cle in  from  12  to  24  hours.  This  hemorrhage  is  soon  followed 
by  gangrene  of  the  part.  I  had,  through  Dr.  Sequard's  cour- 
tesy, the  opportunity  of  examining  such  ears,  and  of  verifying 
the  fact  of  the  subsequent  gangrene.  The  hemorrhage  usually 
occurs  in  the  fossa  navicularis  of  the  auricle.  This  hemor- 
rhage usually  takes  place  on  the  same  side  with  that  of  the 
section. 

Dr.  Sequard  also  stated  that  sections  of  the  sciatic  nerve, 
by  reflex  action  upon  the  medulla,  would  produce  the  same 
result,  and  that  he  had  produced  in  his  own  person  flushing 
of  the  auricle  by  pinching  the  sciatic  nerve. 

Dr.  Sequard  believes  that  disease  of  the  base  of  the  brain, 
which  is,  however,  not  always  attended  by  insanity,  is  the 
cause  of  hsematoma  auris.  In  the  human  animal,  gangrene  is 
not  apt  to  result  from  the  hemorrhage  ;  probably  because  the 
thicker  tissue  of  the  human  auricle  has  a  greater  resisting 
power. 

It  will  thus  be  seen  that  Dr.  Sequard's  views  confirm  those 


QTH2EMAT0MATA. 


113 


of  Dr.  Hun,  while  they  shed  a  new  light  upon  the  valuable 
clinical  observations  of  the  latter. 

Any  inflammation  of  the  integument,  connective  tissue,  and 
cartilage  of  the  auricle,  leading  to  effusion  of  serum,  blood,  or 
the  formation  of  pus,  will  be  apt  to  cause  a  deformity  of 
the  part ;  but  such  a  case  should  be  distinguished  from  an 
othematoma. 


Pig.  30. 


Auricle  Deformed  by  Inflammation. 

The  sketch  from  a  photograph,  which  is  here  given,  shows 
the  result  of  what  was  at  first  an  inflammation  of  the  cartila- 
ginous portion  of  the  auditory  canal.  A  polypus  formed  from 
the  prolonged  use  of  poultices,  the  inflammation  extended  to 
the  tissue  of  the  auricle,  and  after  a  long  period  of  suffering, 
during  which  small  abscesses  were  formed,  which  were  evac- 
uated, after  pursuing  a  sinuous  course  in  the  integument,  the 
auricle  attained  the  shape  which  is  here  shown.  The  hearing 
power  is  unimpaired  when  the  very  small  meatus  is  kept 
open. 

From  all  that  has  been  written  of  vascular  tumors  of  the 


114  MALIGNANT  DISEASE. 

ear,  and  from  my  own  experience,  I  think  we  may  safely 
affirm — 

First.  That  there  are  two  distinct  varieties  of  othsema- 
tomata  :   Traumatic  and  Idiopathic. 

Second.  That  the  idiopathic  is  much  more  common  among 
the  insane  than  among  others,  but  that  identically  or  nearly 
the  same  affection  does  occur  among  the  sane.  It  is  proba- 
ble, however,  from  Brown-Sequard's  experiments,  that  the 
affection  is  caused  by  some  lesion  of  the  base  of  the  brain,  so 
that  although  persons  suffering  from  vascular  tumor  of  the 
ear .  may  not  always  be  insane,  they  generally  have  brain 
disease. 

Third.  The  traumatic  form  differs  from  the  idiopathic  in 
being  a  simple  extravasation  of  blood  from  vessels  ruptured 
by  violence.  In  such  cases  the  deformity  resulting  from  the 
spontaneous  effusions  does  not  occur,  unless  among  profes- 
sional pugilists,  where  the  violence  is  frequently  repeated,  and 
the  auricle,  from  repeated  hemorrhages,  assumes  a  shape  like 
that  resulting  from  a  true  othematoma. 

MALIGNANT  DISEASE. 

Epithelioma. — The  auricle  is  sometimes,  although  not  fre- 
quently, the  seat  of  malignant  disease.  I  have  observed  one 
case  of  epithelioma  of  this  part,  in  which  the  whole  auricle 
was  destroyed,  and  the  disease  had  invaded  the  auditory  canal. 
I  lost  sight  of  the  patient  after  some  weeks,  and  I  can  give  no 
account  of  the  subsequent  course  of  the  disease,  which  was 
unchecked  by  the  treatment  adopted — the  application  of 
fuming  nitric  acid.  Dr.  J.  Orne  Green,  of  Boston,*  also  re- 
ports a  case,  and  quotes  one  from  Yelpeau. 

Epithelioma  of  the  auricle  usually  begins  as  a  small  papule, 
which  finally  develops  into  an  open  ulcer.  This  spreads  very 
rapidly,  involving  finally  the  auditory  canal  and,  unless  ar- 
rested, the  deeper  parts. 

Excision  or  amputation  of  the  parts  is  the  only  proper 
treatment.     "When  the  auricle  alone  is  involved,  this  is  very 

*  Transactions  American  Otological  Society,  third  year. 


ECZEMA   OF  THE  AUEICLE.  115 

easily  accomplished.  In  the  healing  process  care  should  be 
taken,  as  suggested  by  Dr.  Green,  to  prevent  the  closure  of 
the  meatus  by  the  cicatrix,  a  result  which  followed  in  the  case 
reported  by  him,  in  consequence  of  the  refusal  of  the  patient 
to  remain  under  observation  until  the  wound  was  healed. 

Sarcoma. — Sarcomatous  tumors  may  occur  on  the  auricle 
as  well  as  in  the  auditory  canal,  where  they  arise  from  the 
cartilaginous  portion.  They  grow  very  slowly,  but  they  may 
extend  to  the  auditory  canal,  causing  external  otitis,  to  the 
middle  ear,  and  even  to  the  labyrinth  and  meninges  of  the 
brain.  Early  removal  is  the  only  safe  means  of  treatment, 
and  even  then  the  growth  may  return. 

Vascular  Neoplasia. — Angioma,  a  form  of  vascular  tumor 
which,  at  first  sight,  according  to  Gruber,  resembles  an  othe- 
matoma, may  occur  on  the  auricle.  The  treatment  that  has 
been  attempted  in  angioma  is,  in  general  terms,  cauterization 
with  various  substances,  or  inoculation  with  vaccine  lymph, 
the  application  of  tartar  emetic  ointment,  or  subcutaneous 
injection  of  dilute  tincture  of  the  sesquichloride  of  iron ;  but 
the  simplest  and  only  effectual  remedy  is  the  amputation  of 
the  affected  portion. 

ECZEMA. 

Eczema  of  the  auricle  is  not  one  of  the  most  frequent 
affections  of  the  ear,  as  shown  by  the  statistics  of  eye  and 
ear  hospitals  and  writers  on  otology ;  but  a  large  number  of 
cases  never  come  under  the  attention  of  special  observers,  and 
are,  consequently,  not  found  in  their  statistics.  Inasmuch  as 
eczema  of  the  auricle  is  usually  attended  by  the  same  disease 
in  the  auditory  canal,  it"  will  be  more  convenient  to  speak  of 
them  both  at  this  time. 

Eczema  of  the  ear  seems  to  occur  more  frequently  among 
females  than  males  ;  but  it  is  found  in  both  sexes.  The  symp- 
toms are  the  same  as  those  of  eczema  in  other  parts  of  the  body, 
with  some  symptoms  peculiar  to  the  ear.  .The  symptoms  pecu- 
liar to  the  ear,  are  redness,  swelling,  and  the  formation  of  vesicles 
which  become  pustular,  and  which  finally  cover  the  whole  re- 
gion with  unsightly  crusts,  from  which  a  discharge  occurs.    The 


116  ECZEMA  OF  THE  AURICLE. 

auricle  becomes  a  misshapen  mass,  while  the  swelling  and  in- 
crustation of  the  integument  lining  the  auditory  passage  and 
membrana  tympani  impair  the  hearing  to  a  serious  extent. 
Fulness  and  noise  in  the  ears  are  then  added  to  the  patient's 
other  symptoms,  and  the  condition  is  unpleasant  in  the  high- 
est degree.  The  disease,  when  left  to  itself,  is  apt  to  have  a 
very  chronic  course,  and  yet  it  is  very  amenable  to  proper 
treatment.  The  causes  of  eczema  are  not  very  clear.  I  have 
usually  observed  it  in  persons  of  weak  constitutions,  and  not 
among  the  strong  and  vigorous.  It  rarely  occurs  upon  the 
auricle  alone  ;  but  it  is  usually  found  in  conjunction  with  the 
same  disease  on  other  parts  of  the  body,  most  frequently  in 
conjunction  with  eczema  of  the  face  and  head,  although  it 
sometimes  occurs  on  the  auricle  and  in  the  meatus  alone. 

According  to  Ausspitz*  formerly  an  assistant  to  Hebra,  the 
great  dermatologist  of  Vienna,  eczema  of  the  ear  differs  from 
the  same  disease  as  it  appears  in  other  parts  of  the  body,  in 
occurring  with  a  greater  amount  of  swelling  and  secretion  of 
a  serous  fluid  than  is  usual,  together  with  the  more  frequent 
appearance  of  fissures  in  the  tissue. 

Treatment. — The  treatment  of  eczema  is  simple,  and  I  have 
usually  found  the  results  very  good.  The  advice  of  Ausspitz, 
to  do  as  little  as  possible  in  the  acute  form,  is  excellent.  The 
auricle  should  be  kept  from  the  air.  This  may  be  accom- 
plished by  the  use  of  oils,  powders,  or  even  by  a  plaster-of- 
Paris  bandage.  A  good  application  is  the  formula  of  Aus- 
spitz : 

R        Flor.  Zinci 3  ij 

Pulv.  Alum  )  __ 

Aniyli  Pulv. )  aa"  '  '" ^J 

M.    Ft.  pulv. 

This  powder  is  dusted  over  the  affected  portion  with  a 
camel' s-hair  brush.  If  the  auricle  be  excoriated  and  sensitive, 
astringent  solutions  of  sulphate  of  zinc  may  be  used. 

At  the  same  time  with  this  local  treatment,  as  in  all  other 
diseases,  the  physician  should  carefully  consider  the  general 

*  AxcMv  fur  Olirenlieilkunde,  Bd.  I.,  p.  124. 


ECZEMA   OF  THE   AUEICLE.  117 

state  of  the  patient,  since  in  this,  a  cause  for  the  eczema  may 
often  be  found,  which  being  removed  by  appropriate  manage- 
ment, will  prevent  a  relapse  of  the  affection. 

Eczema  of  the  auricle  and  auditory  canal  is  not  often 
brought  to  the  notice  of  the  surgeon  until  it  has  become 
chronic.  Its  treatment  then  may  require  the  greatest  patience 
and  care  The  treatment  which  I  have  found  usually  success- 
ful is  the  following :  The  auricle  is  carefully  poulticed  with 
flax-seed  meal  until  all  the  crusts  can  be  removed,  and  is  then 
anointed  with  an  ointment  of  the  sulphate  of  iron  and  simple 
cerate,  in  the  proportions  of  from  one  to  two  grains  of  the 
former  to  a  drachm  of  the  latter.  This  ointment  is  applied  as 
often  as  may  be  necessary  to  keep  the  part  constantly  anointed, 
until  the  vesicles  have  ceased  to  form. 

The  local  treatment  of  the  auditory  canal  is  often  unsuc- 
cessful from  the  want  of  the  personal  attention  of  the  physi- 
cian. No  one  who  is  unable  to  examine  the  external  opening 
of  the  ear  down  to  the  membrana  tympani,  can  tell  when  it  is 
or  is  not  clean.  Without  a  thorough  removal  of  the  material 
thrown  off  in  an  eczema,  there  can  be  no  cure.  An  eczema- 
tous  auricle  may  perhaps  recover  spontaneously,  an  eczema- 
tous  auditory  canal  will,  probably,  never  thus  return  to  a 
normal  condition.  The  material  thrown  off  from  the  inflamed 
integument  collects  in  the  narrow  passage,  and  by  mechan- 
ical irritation  increases  the  swelling,  and  produces  the  most 
troublesome  symptom  of  the  disease — deafness.  The  audi- 
tory canal  should  be  therefore  carefully  cleansed  every  day 
with  the  syringe  and  angular  forceps  or  cotton-holder,  under 
a  good  illumination  with  the  otoscope,  and  then  an  appro- 
priate liquid  application  be  made.  A  liquid  preparation  is  to 
be  preferred  to  an  unctuous  one,  for  the  simple  reason  that 
an  ointment  will  again  block  up  the  passage,  and  thus  pre- 
vent the  patient  from  securing  the  full  benefit  to  his  hearing 
power  which  the  removal  of  the  epidermis,  crusts,  and  pus  has 
produced.  We  may  fail  to  cure  many  a  case  of  disease  of  the 
integument  lining  this  part,  if  we  do  not  carry  out  our  own 
advice ;  we  should  never  give  over  the  treatment  into  the 
hands  of  the  parents  or  attendants  of  the  patient,  for  they 
will  be  incompetent  assistants. 


118  ECZEMA  OF  THE  AUKICLE. 

The  warm  douche  is  very  valuable  in  the  treatment  of 
chronic  eczema  of  the  canal.  It  allays  itching  sensations, 
and  is  usually  very  grateful  to  the  patient.  The  use  of  the 
douche  may  be  entrusted  to  the  patient  himself.  It  is  well  to 
use  it  very  often  in  the  early  periods  of  treatment,  say  once  an 
hour.  The  warm  water  is  a  direct  antiphlogistic  ;  I  have  seen 
its  use  alone,  cure  most  obstinate  cases  of  inflammation  of  the 
canal,  that  have  existed  for  years. 

The  only  specific  remedy  for  internal  use  in  chronic  eczema 
of  the  auricle,  as  well  as  that  of  the  same  disease  in  other 
parts  of  the  body,  is  arsenic.  In  very  chronic  cases  I  usually 
give  Fowler's  solution  in  connection  with  the  local  treatment, 
and  it  is  usually  of  great  avail. 

I  am  aware  of  various  other  modes  of  treating  eczema, 
and  of  the  almost  innumerable  applications  which  are  recom- 
mended ;  but  I  feel  confident  that  that  which  I  have  sketched 
will  serve  its  purpose  so  well,  when  modified  by  individual 
judgment  in  practice,  as  to  fulfil  all  reasonable  requirements. 

Calcareous  formations  are  often  found  in  the  auricle,  in 
persons  of  a  gouty  habit,  as  in  other  parts  of  the  body. 
These  symptoms  of  gout  often  cause  a  great  deal  of  local  pain, 
which  is  sometimes  relieved  by  an  unctuous  application  to  the 
hardened  and  tender  parts.  Dr.  Garrod*  of  London,  first 
called  attention  to  these  formations,  which  he  found  to  be 
urate  of  soda.  They  were  most  frequently  found  by  Garrod 
on  the  upper  border  of  the  helix,  and  were  supposed  not  to 
exist  on  the  lower  part  of  the  auricle ;  but  I  found  what  seemed 
to  be  such  a  formation,  in  the  concha  of  a  gentleman  who  suf- 
fered from  gout.  Unlike  those  cases  reported  by  Dr.  Garrod, 
this  spot  was  very  painful. 

*  Von  Troltsch,  Diseases  of  the  Ear,  p.  56. 


CHAPTER    V. 

DIFFUSE   AND   CIRCUMSCRIBED   INFLAMMATION   OF   THE 
EXTERNAL  AUDITORY  CANAL. 

The  affections  of  the  external  auditory  canal  may  be  con- 
veniently arranged  as  follows  : 

I. — Diffuse  inflammation. 
II. — Circumscribed  inflammation. 
III. — Vegetable  fungous  growths. 
IV. — Inspissated  cerumen. 
V. — Eczema. 
VI.- — Foreign  bodies. 
VII.— Polypi. 

VLH. — Exostoses  and  hyperostoses. 
IX. — Syphilitic  condylomata  and  ulcers. 

To  avoid  any  misconception,  I  would  remark  that  while 
bony  growths  (exostoses  and  hyperostoses)  are  classed  under 
the  affections  of  the  external  auditory  canal,  they  are  actually 
consequences  of  inflammations  of  the  middle  ear.  It  will 
therefore  be  more  appropriate  to  consider  this  rather  impor- 
tant subject  under  the  head  of  diseases  of  the  cavity  of  the 
tympanum.  An  account  of  their  pathology  and  treatment 
will  be  found  in  the  chapter  devoted  to  the  Consequences  of 
Chronic  Suppuration  of  the  Middle  Ear.  The  subject  of  Aural 
Polypi  will  also  be  deferred  until  a  subsequent  chapter,  for 
they  are  also  much  more  frequently  the  result  of  inflammation 
of  the  middle  ear,  than  of  disease  of  the  external  auditory 
canal. 

Otitis  externa  is  the  generic  term  for  all  the  various  forms 
of  inflammation  of  the  external  auditory  passage,  but  it  is  not 
specific  enough  for  any  exact  study  of  these  affections. 


120  DIFFUSE  INFLAMMATION. 

Inflammations  of  the  external  auditory  canal  are  much 
more  rare  than  those  of  the  middle  ear  ;  of  1000  cases  of  the 
different  varieties  of  aural  disease  observed  by  myself  in  pri- 
vate practice,  but  132  were  cases  of  affections  of  the  outer  ear. 
This  proportion  is  about  the  same  in  the  statistics  of  other 
authors  and  those  of  public  institutions. 

Some  writers  speak  of  the  inflammations  of  the  external 
auditory  passage  as  being  catarrhal  in  its  nature  ;  but  as  Yon 
Troltsch  strongly  insists,  and  as  has  already  been  said  in  the 
description  of  the  anatomy  of  the  auditory  canal,  there  cannot 
be  catarrhal  inflammation  where  there  is  no  mucus  membrane. 
The  lining  of  this  passage  is  integument,  and  in  no  proper 
sense  can  we  speak  of  a  catarrh  of  the  integument. 

DIFFUSE   INFLAMMATION. 

I  will  first  give  an  account  of  the  diffuse  form  of  inflam- 
mation of  the  auditory  canal. 

Symptoms. — The  subjective  symptoms  of  diffuse  inflamma- 
tion of  the  external  auditory  canal  are  itching  sensations  in 
the  canal,  pain,  and  a  sense  of  fulness. 

I  speak  of  these  symptoms  in  the  order  in  which,  on  care- 
ful examination  of  the  history  of  the  cases,  I  have  found  they 
usually  appear.  It  is  true  that  patients  often  give  a  period 
later  than  the  one  in  which  the  itching  sensations  occurred,  as 
the  one  in  which  their  ears  first  troubled  them,  but  ears  in  a 
normal  state  have,  so  to  speak,  no  sensations  ;  that  is  to  say, 
they  are  not  thought  of,  and  need  no  especial  care.  When  an 
ear  begins  to  require  something  to  relieve  itching  sensations, 
it  is  already  diseased. 

The  objective  symptoms  are  impairment  of  hearing,  red- 
ness of  the  canal  and  of  the  membrana  tympani,  swelling,  and, 
at  a  subsequent  period,  suppuration  of  the  epidermis  and 
integument.  In  the  lower  part  of  the  canal,  dealing  as  we  do 
with  periosteum,  the  pain  will  be  intense,  like  that  from  a 
paronychia.  An  inflammation  of  integument  that  is  so  tightly 
bound  down  to  the  bone  as  is  this  portion  of  the  integumen- 
tary lining  of  the  auditory  canal,  can  but  be  essentially  a 
periostitis. 


DIFFUSE  INFLAMMATION.  121 

Prolonged  suppuration  of  the  integument,  or  even  suppu- 
rative action  that  has  been  of  short  duration,  but  violent,  may 
produce  polypi,  or,  as  I  prefer  to  call  them,  granulations,  in 
the  external  auditory  canal.  I  have  the  notes  of  four  such 
cases.  One,  that  of  a  lady,  was  complicated  by  a  precedent 
inflammation  of  the  cavity  of  the  t}Tmpanum  ;  but  the  inflam- 
mation of  the  external  auditory  canal  was  an  independent  one. 
Very  large  granulations,  or  polypi,  sprang  up  in  a  few  days 
after  a  poultice  had  been  applied.  This  poultice  was  ordered 
by  the  attending  physician  to  relieve  the  initial  pain  of  an  in- 
flammation of  the  canal,  such  as  sometimes  occurs  from  the 
continued  instillation  of  astringents.  It  was  applied  for  some 
days  through  a  misunderstanding  of  the  damage  that  might 
ensue,  and  very  large  granulations  formed. 

The  second  case  occurred  in  an  Irish  laborer,  whom  I  saw 
at  my  clinic  in  the  University  Medical  College.  I  removed  a 
large  polypus  from  the  meatus,  which  the  patient  stated  posi- 
tively had  occurred  in?  a  few  days,  and  that  he  had  never  pre- 
viously suffered  from  disease  of  the  ear.  After  the  treatment 
had  progressed  for  some  time,  I  found  that  the  inflammation 
was  confined  to  the  canal  and  the  outer  layer  of  the  drum- 
head, and  that  his  statement  as  to  the  existence  of  previous 
disease  was  probably  correct.  I  could  find  no  cause  for  the 
rapid  course  of  the  inflammation. 

The  third  case  I  saw  at  the  Brooklyn  Eye  and  Ear  Hos- 
pital. The  trouble  in  the  ear  had  lasted  seven  days,  and  here 
also  there  was  a  large  polypus. 

The  fourth  case  was  that  of  a  lady  whom  I  saw  in  pri- 
vate practice.  She  suffered  from  what  she  supposes  to  have 
been  an  abscess  or  furuncle  of  the  external  meatus.  It  was 
lanced,  and  then  poultices  were  applied.  I  saw  her  six  days 
after.  She  had  used  the  poultices  nearly  the  whole  of  the  six 
days.  I  found  the  canal  blocked  up  by  a  polypus  as  large  as 
a  filbert,  growing  from  the  anterior  wall  of  the  canal.  The 
final  result  of  this  case  in  deformity  of  the  auricle,  is  seen  in 
the  engraving  on  page  113. 

The  microscopic  appearances  of  the  growths  are  identical 
with  those  of  polypi  springing  from  the  mucous  membrane  of 


122  DIFFUSE  INFLAMMATION — CAUSES. 

the  cavity  of  the  tympanum,  which  will  be  fully  discussed  in 
a  subsequent  chapter. 

Although  it  is  anticipating  somewhat  of  what  should  be 
said  under  the  head  of  treatment,  I  will  here  state  that  the  un- 
doubted cause  of  these  growths,  in  two  of  the  cases  just  given, 
was  the  prolonged  use  of  the  poultices.  Yon  Troltsch  called 
attention  to  the  fact  that  poultices  produced  tedious  suppura- 
tion ;  but  I  believe  this  is  the  first  intimation  that  they  cause 
the  sprouting  up  of  exuberant  granulations  in  the  canal. 

Causes. — The  causes  of  the  diffuse  form  of  inflammation  are 
various.  Irritation  of  the  ear  by  means  of  ear-picks,  by  hair- 
pins, favorite  instruments  with  women  ;  the  instillation  of  such 
agents  as  Harlem  oil,  Cologne  water,  camphorated  oil,  and  so 
on,  are  frequent  causes  of  an  inflammation  of  this  part.  There 
is  probably  some  antecedent  inflammation  of  the  integument 
which  causes  a  resort  to  those  agents,  to  relieve  the  trouble- 
some itching  sensations.  Cold  draughts  of  air  are  often 
spoken  of  as  causes  of  inflammation  of  the  outer  canal ;  but 
such  influences  are  more  apt  to  produce  an  inflammation  of 
the  naso-pharyngeal  space,  and  through  that  of  the  middle  ear. 
In  fact,  the  causes  of  external  otitis  diffusa  seem  to  be  chiefly 
local,  if  I  may  so  speak ;  that  is,  the  disease  is  caused  by  me- 
chanical causes  acting  locally.  There  may,  however,  be  an 
antecedent  eczematous  inflammation  before  the  diffuse,  non- 
eruptive  form  begins. 

Of  late  an  apparatus,  consisting  of  a  very  small  sponge 
attached  to  an  appropriate  handle,  and  called  an  aurilave,  has 
been  devised,  and  is  sold  largely  by  apothecaries  as  an  instru- 
ment for  cleansing  the  ear.  It  does  a  great  deal  of  harm.  By 
its  use  the  secretions  are  packed  in  the  ear,  and  inflammation 
of  the  integument  or  inspissation  of  the  cerumen  is  very  often 
caused. 

Physicians  are  often  asked  if  the  outer  ear  should  be  pro- 
tected from  the  cold  air  by  a  plug  of  cotton,  ear  muffs,  or 
similar  means.  The  beginning  of  aural  inflammation  is  rarely 
from  the  auditory  canal,  although  the  auricle  is  sometimes 
frozen  from  exposure  to  cold.  If,  however,  a  person  sit  in  a 
railway  carriage  which  is  going  very  fast,  with  the  ear  next 


DIFFUSE  INFLAMMATION — TREATMENT.  123 

to  an  open  window,  or  if  the  auditory  canal  and  mernbrana 
tympani  be  exposed  in  any  similar  manner  to  a  draught  of  air, 
an  inflammation  of  the  canal  and  of  the  tympanic  cavity  may 
ensue.  But  when  there  is  no  such  draught  upon  the  ear,  as, 
for  instance,  when  a  person  is  walking  or  driving  in  the  open 
air,  there  is  no  need,  unless  there  is  danger  that  the  auricle 
will  be  frost-bitten,  of  using  a  covering  to  the  meatus  audito- 
rius  any  more  than  to  the  nostrils.  The  natural  curvatures 
of  the  canal  will  prevent  a  current  of  air  from  reaching  the 
drum-head.  This  is,  however,  only  true  as  respects  healthy 
ears.  In  cases  of  chronic  aural  catarrh,  and  in  the  other 
.kinds  of  middle  ear  troubles,  the  canals  sometimes  become 
very  sensitive  to  the  cold,  and  require  protection  when  healthy 
ears  do  not.  When  no  inconvenience  is  felt  from  allowing  the 
ears  to  remain  uncovered,  it  is  better  to  leave  them  without 
protection.  The  habit  of  plugging  the  auditory  canals  with 
cotton  on  every  slight  pretext  is  a  bad  one,  because  it  is  apt 
to  cause  the  ears  to  become  over-sensitive.  As  I  have  said, 
we  do  not  usually  get  an  inflammation  of  the  ear  from  an 
exposure  of  the  auditory  canal,  but  from  such  causes  as 
wet  feet,  an  exposure  of  the  whole  surface  of  the  body,  and 
so  on. 

There  is  altogether  too  much  solicitude  on  the  part  of 
mothers  and  other  persons  as  to  the  cleanliness  of  their  chil- 
dren's or  their  own  ears.  The  auricle  and  the  edges  of  the 
opening  into  the  canal,  which  are  about  all  that  the  little  fin- 
ger will  reach,  are  the  only  parts  of  the  organ  that  require 
cleansing  when  the  ears  are  in  a  state  of  health.  Any  further 
manipulations  with  towels,  ear-spoons,  and  so  on,  are  med- 
dlesome, and  may  become  dangerous  to  the  health  of  the 
canal. 

Treatment. — An  attack  of  otitis  externa  diffusa  in  an  adult 
may  be  usually  cut  short  by  the  use  of  leeches.  They  should 
be  applied,  as  Wilde  long  ago  pointed  out,  not  on  the  mastoid 
process  but  on  the  tragus,  for  the  reason  which  Von  Troltsch 
gives,  that  in  this  place  the  vessels  which  supply  the  canal 
and  outer  layer  of  mernbrana  tympani  are  most  conveniently 
and  surely  reached.     Leeches  in  this  form  of  disease  are  not 


124 


AUSAL  DOUCHE. 


as  certain  in  their  effects,  however,  as  when  used  for  an  inflam- 
mation of  the  middle  ear ;  when,  as  we  shall  see,  they  exert  an 
almost  magical  influence,  so  rapid  is  their  effect.  In  the  early 
stages  of  the  disease,  when  the  pain  is  severe,  and  suppura- 
tion has  not  yet  occurred,  but  the  canal  is  red,  swelled,  and 
sensitive,  great  benefit  will  be  produced  by  scarifications  of  the 
cartilaginous  wall.  This  scarification  is  made  with  a  tenotomy 
knife.  The  incisions  should  be  from  three-fourths  to  an  inch 
long  on  the  walls  of  the  canal,  as  recommended  by  Gruber,  of 
Vienna.  Warm  water  should  also  be  allowed  to  run  into  the 
ear,  by  means  of  Clarke's  aural  douche,  or  any  similar  means. 


Fig.  31. 


E.  H.  Clarke's  Aural  Douche. 

"When  patients  are  told  to  apply  warm  water  to  the  ear,  unless 
they  are  particularly  instructed,  they  will  almost  invariably 
use  the  syringe,  thinking  that  is  the  way  in  which  the  water  is 
to  be  applied  ;  but  what  is  required  is  the  steady  flow  of  warm 
water  upon  the  part,  and  this  is  best  attained  by  means  of  the 
douche.  Patients  should  be  instructed  in  its  use,  and  espe- 
cially should  they  be  told  that,  unless  the  auricle  is  kept  on 
the  stretch,  so  that  the  walls  of  the  canal  are  apart,  the  water 
will  not  enter  the  ear.  The  douche  is  the  same  as  the  so- 
called  nasal  douche  of  Weber,  and  is  very  valuable  in  cases 
of  aural  inflammation.  As  has  been  seen  in  the  first  chap- 
ter, Hippocrates  advised  the  use  of  warm  water  to  the  ear  for 


DIFFUSE   INFLAMMATION — TREATMENT.  125 

the  relief  of  pain,  but  it  fell  into  undeserved  disuse  until  the 
value  of  its  application  was  reinforced  upon  the  minds  of  a 
profession  filled  with  the  idea  of  the  virtues  of  composite  "  ear- 
drops." 

Of  late  the  cup  has  been  made  of  soft  rubber,  and  it  thus 
becomes  much  more  convenient  to  carry  about.  In  the  ab- 
sence of  the  cup,  a  bit  of  rubber  tubing  and  an  ordinary  bowl, 
by  the  application  of  the  principle  of  the  syphon,  will  make  an 
efficient  and  simple  douche. 

The  value  of  the  aural  douche  is  by  no  means  limited  to 
cases  of  inflammation  of  the  outer  portions  of  the  ear.  In 
acute  inflammations  and  chronic  suppurations  of  the  middle 
ear,  it  becomes  a  very  valuable  means  of  alleviating  pain  and 
of  cleansing  the  ear.  For  the  latter  purpose  it  is  especially 
valuable  among  children. 

If  the  use  of  the  leeches,  the  employment  of  scarification, 
and  the  warm  douche  do  not  wholly  subdue  the  pain — which 
is  quite  unlikely — a  small  flax-seed  poultice  may  be  applied  in 
the  canal ;  but  the  ear  should  not  be  covered  by  a  large  poul- 
tice, as  is  often  done ;  such  poultices  relax  the  tissue  to  so 
great  an  extent  that  granulations  or  polypi  are  apt  to  spring 
up  from  the  softened  and  loosened  tissue,  as  we  have  seen  in 
the  cases  that  I  have  detailed.  A  poultice  should  never  be 
applied  to  or  on  the  ear  for  more  than  a  few  hours.  They  are 
almost  as  dangerous  a  remedy  in  aural  as  in  ophthalmic 
practice,  where  they  have  caused  the  loss  of  many  eyes. 

At  night  the  ear  should  be  kept  warm  by  wrapping  it  in 
cotton,  and  the  patient  should  lie  on  a  pillow  that  is  warmed 
from  beneath,  by  means  of  a  rubber  bag  filled  with  hot  water, 
or  some  similar  contrivance.  By  attention  to  these  details 
much  suffering  will  be  spared  the  patient,  and  the  course  of 
the  affection  will  be  shortened.  In  addition  to  the  local  treat- 
ment it  will  sometimes  be  necessary,  although  not  often,  to 
give  one  of  the  preparations  of  morphine,  or  a  dose  of  chloral 
internally.  I  have  not  found  much  advantage  from  the  addi- 
tion of  narcotics  to  the  warm  water  instillations,  although 
there  may  be  some  benefit  from  their  use.  Magendie's  solu- 
tion of  morphia  is  the  agent  I  usually  employ  in  the  ear,  using 
about  one  part  to  eight  of  water,  dropped  when  warm  into  the 


126  DIFFUSE  INFLAMMATION — TREATMENT. 

canal.  The  popular  remedies  for  ear-ache,  dependent  upon 
whatever  cause,  are  usually  sweet-oil  and  laudanum,  molasses, 
Harlem  oil,  glycerine,  and  a  roasted  onion.  The  oil,  lauda- 
num, and  molasses  are  tolerably  efficient;  but  although  they 
are  useful  in  their  property  of  stilling  pain,  they  are  far  infe- 
rior to  the  leeches,  scarification,  and  warm  water.  I  have 
seen  children,  who  had  been  suffering  from  severe  pain  in  the 
ear,  drop  off  to  sleep  in  a  few  moments  after  a  tablespoonful 
of  warm  water  was  poured  into  the  ear ;  and  yet  I  am  very 
sorry  to  say  that  there  are  some  rare  cases  where  warm  water 
seems  to  aggravate  the  pain  ;  but  the  leeches  scarcely  ever 
fail  us. 

The  onion  acts  just  as  the  conical  flax-seed  poultice,  and 
may  be  resorted  to  if  the  warm  water  fails,  and  leeches  are 
not  to  be  had.  Harlem  oil,  and  all  similar  stimulating  appli- 
cations, do  nothing  but  harm,  and  increase  the  sufferings  of 
the  distressed  patient.  The  laity  resort  to  such  applications, 
and  submit  for  days  to  pain  in  the  ear,  without  going  to  a 
physician,  because  they  have  been  taught  by  sad  experience 
that  doctors  pay  very  little  attention  to  an  ear-ache — and  yet 
what  pain  is  worse?  Warm  vapor  of  any  kind,  the  smoke 
from  a  cigar,  for  example,  is  very  grateful  to  an  inflamed  audi- 
tory canal  or  membrana  tympani ;  and  a  steam  nebulizer  be- 
comes at  some  times  a  very  useful  adjuvant  in  treatment  of 
acute  aural  inflammations.  Sometimes,  children,  who  awake 
at  night  with  ear-ache,  may  be  quieted  by  breathing  into  the . 
auditory  canal. 

Some  practitioners  are  in  the  habit  of  indiscriminately 
advising  blisters  behind  the  ear  in  all  forms  of  aural  disease, 
whether  acute  or  chronic.  Whatever  may  be  their  virtue  in 
chronic  disease,  they  are  only  an  aggravation  in  the  acute 
forms  of  aural  inflammation,  and  must  give  a  patient  an  unfa- 
vorable idea  of  the  benefits  of  counter-irritation.  Speedy 
relief  from  the  severe  pain  of  otitis  is  as  imperative  as  in  peri- 
tonitis or  iritis,  and  I  have  dwelt  on  the  various  remedies  at 
some  length,  in  order  that  the  practitioner  may  be  at  no  loss 
for  some  agent  that  will  cut  short  the  inflammatory  action. 
I  will  tabulate  the  remedies  in  the  order  that  1  consider  them 
valuable :  1.  Leeches  ;  2.  Scarifications ;  3.  Warm  douche ;  4. 


SYEINGING  THE  EAE.  127 

Conical  poultice  in  the  canal ;  5.  Steam  or  warm  vapor ;  6. 
Opium  or  chloral. 

Dr.  A.  D.  Williams,  of  St  Louis,  has  recommended  the  use 
of  a  solution  of  a  sulphate  of  atropia,  two  grains  to  the  ounce, 
which  is  dropped  into  the  auditory  canal  as  a  remedy  for  the 
relief  of  the  pain  from  aural  inflammation.  I  have  not  as  yet 
had  sufficient  experience  in  its  use  to  give  an  opinion  as  to 
the  value  of  the  remedy  in  this  class  of  cases.  A  suggestion 
from  such  a  competent  observer  is  well  worthy  of  attention. 

Most  adult  patients  go  about  while  suffering  from  external 
diffuse  otitis.  During  the  more  acute  stages  it  would  be  bet- 
ter to  keep  them  in-doors  and  in  bed.  If  this  can  be  accom- 
plished, the  use  of  diaphoretics  will  aid  the  local  treatment. 

If,  in  spite  of  our  efforts,  suppuration  is  once  fairly  estab- 
lished, or  if  the  disease  has  advanced  to  this  point  when  first 
seen  by  the  practitioner,  we  must  endeavor  to  limit  the  suppu- 
ration. To  this  end  thorough  cleansing  of  the  ears  is  neces- 
sary. This  is  best  accomplished  by  syringing — a  simple  pro- 
cedure, but  one  which  many  physicians  are  unable  to  carry 
out  efficiently  and  with  neatness.  The  appliances  necessary 
for  a  thorough  syringing  of  the  ear  are,  first,  a  good  syringe. 
I  think  the  small  hard-rubber  syringe  is  the  best,  although  a 
Davidson's  syringe  does  very  well.  The  glass  syringes  are  of 
no  use  whatever. 

Fig.  32. 


Hard  Bubber  Syringe. 

Then  we  need  a  bowl — a  small  one,  not  a  large  wash-bowl, 
but  one  such  as  is  used  as  a  finger-bowl — being  thin  and  easily 
held — and  a  receptacle  for  the  warm  water  which  is  to  be  used 
in  the  syringing  process.  No  towels  or  napkins  are  needed 
about  the  neck,  to  prevent  spilling  the  water ;  no  assistant  be- 
side the  patient  is  required,  if  he  be  an  adult,  and  if  the  proce- 


128 


SYRINGING  THE  EAR. 


dure  be  carried  out  as  will  be  described.  The  patient  being 
seated,  holds  tlie  bowl  well  under  the  auricle,  in  the  hollow 
just  under  the  lobe,  keeping  the  head  perfectly  straight,  and 
using  both  hands  to  steady  the  vessel.  The  surgeon  should 
thoroughly  straighten  the  auditory  canal  with  the  left  hand, 
and  placing  the  nozzle  of  the  syringe  well  into  the  meatus, 
direct  the  stream  with  the  right,  down  to  the  membrana  tym- 
pani.  It  is  well  to  prepare  the  patient  for  the  shock  of  the 
water,  by  allowing  a  part  of  the  first  syringeful  to  pass  into 
the  concha,  and  not  into  the  canal. 

Fig.  33. 


Method  of  Syringing  the  Ear. 


It  will  be  seen,  that  no  patient  is  capable  of  thoroughly 
syringing  his  own  ear,  and  that  no  person  who  has  not  been 
taught  the  simple  process  will  be  able  to  accomplish  the  object 
for  which  syringing  is  undertaken,  that  is,  the  cleansing 
of  the  auditory  canal  and  the  outer  surface  of  the  membrana 


SYRINGING  THE  EAR.  129 

tympani.  Notwithstanding  these  facts,  patients  suffering  from 
an  ulcerative  process  in  the  ear,  and  who  require  the  daily 
removal  of  the  pus  as  an  essential  to  recovery,  are  often  sent 
away  without  other  instruction  than  the  advice  to  syringe  the 
ear.  It  is  almost  as  difficult  for  a  person  to  properly  syringe 
his  own  ear,  as  to  cauterize  his  own  palpebral  conjunctiva. 
We  certainly  should  never  think  of  leaving  the  latter  manipu- 
lation to  any  but  a  person  who  had  been  taught  to  manage  it 
properly. 

The  ear  affected  with  chronic  external  otitis  should  be 
cleansed  from  one  to  three  times  daily,  while  the  secretion  is 
at  its  height.  This  cleansing  should  always  be  done  under  a 
good  illumination  by  means  of  the  otoscope  attached  to  a 
forehead  band.  The  parts  should  be  then  dried  by  means  of 
cotton  twisted  about  a  thin  bit  of  wood,  or  a  steel  cotton- 
holder. 

The  agents  which  may  be  used  in  checking  ulceration  are 
numerous.  I  prefer  solutions  of  nitrate  of  silver,  of  alum,  and 
of  the  sulphates  of  zinc  and  copper,  to  the  others.  The  nitrate 
of  silver  I  use  in  strong  solutions,  from  20  to  40  grains  to 
the  ounce,  pencilled  over  the  parts ;  the  sulphates  and  the 
alum  in  solutions  of  from  1  to  4  grains  to  the  ounce,  instilled 
into  the  ear.  The  choice  of  the  astringent  is,  however,  much 
less  important  than  the  thorough  removal  of  the  pus,  which 
should  be  done  at  least  three  times  a  week,  and,  if  possible, 
daily,  by  the  physician  himself. 

"What  may  be  done  for  a  neglected  suppuration  of  the 
auditory  canal,  by  the  mere  daily  removal  of  the  pus  and  the 
application  of  a  caustic  or  astringent,  however  many  altera- 
tives and  other  constitutional  remedies  may  have  been  taken 
in  vain,  is  sometimes  marvellous. 

The  practitioner  should  always  be  on  his  guard,  lest  he 
mistake  a  chronic  suppuration  in  the  middle  ear  for  one  of  the 
auditory  canal,  with  an  intact  membrana  tympani.  It  will  be 
seen  by  the  statistics  in  the  chapter  on  the  former  disease,  that 
a  long-continued  suppuration  in  the  ear  usually  has  its  origin, 
not  in  the  canal,  or  outer  layer  of  the  drum-head,  but  in  the 
cavity  of  the  tympanum  whence  it  advances  and  perforates  the 
membrana  tympani.     Chronic  suppuration  from  the  external 


130  FUEUNCLES  IN  THE  AUDITOEY  CANAL. 

auditory  canal,  contrary  to  what  has  often  been  written  upon 
this  subject,  and  contrary  to  the  opinion  of  most  practitioners 
with  whom  I  have  conversed  on  this  subject,  is,  judging  from  my 
experience,  a  rare  disease.  When  it  does  exist,  it  is,  if  properly 
treated,  by  the  free  use  of  warm  water  astringents,  and  leeches, 
if  need  be,  exceedingly  tractable,  and  almost  always  curable. 

CIRCUMSCRIBED  INFLAMMATION  OP  THE   EXTERNAL  AUDITORY 
CANAL,  OR  FURUNCLES  OF  THE  CANAL. 

By  circumscribed  inflammation  occurring  in  this  part  we 
simply  mean  furuncles.  They  generally  arise  in  connection 
with  the  existence  of  furuncles  in  other  parts  of  the  body,  and 
are,  like  them,  very  painful.  They  also  produce  deafness  by 
mechanically  closing  the  auditory  canal.  Tinnitus  aurium — 
noise  in  the  ears — a  symptom  which  is  apt  to  be  very  trouble- 
some in  almost  all  other  aural  affections,  is  not  generally 
present  when  f  uruncular  inflammation  exists.  It  may  be,  how- 
ever, after  the  pus  from  the  boil  has  been  evacuated,  and  some 
of  it,  perhaps,  remains  in  the  canal  and  presses  upon  the  mem- 
brana  tympani,  and  through  it  upon  the  ossicula  aitditus  and 
auditory  nerve.  The  tinnitus  is  absent  in  the  early  stages, 
because  there  is  no  pressure  exerted  upon  the  drum-head  by 
a  circumscribed  swelling  of  the  canal. 

There  will  be  no  difficulty  in  the  diagnosis,  if  the  ear  be 
examined  by  means  of  the  mirror,  or  otoscope,  and  reflected 
daylight  or  sunlight.  One  or  more  circumscribed  swellings 
are  found  in  the  caliber  of  the  canal.  Their  usual  situation  is 
a  point  near  the  tragus,  on  the  anterior  wall,  and  we  may  have 
two  or  more  at  a  time. 

The  proper  treatment  is  to  make  an  incision  at  as  early  a 
period  as  possible,  and  then  to  continuously  apply  warm  water, 
giving  the  ear  an  uninterrupted  warm  bath,  as  it  were. 

It  makes  no  difference  whether  pus  or  blood  be  evacuated 
by  the  incision.  The  relief  following  is  generally  immediate  in 
either  case.  The  incision  is  best  made  with  a  sharp-pointed 
curved  bistoury,  cutting  from  below  upwards,  and  not  with 
a  scalpel  down  upon  it,  as  the  books  usually  advise.  It  can 
thus  be  made  more  quickly,  and  does  not  cause  as  much  pain 


FURUNCLES  IN  THE  AUDITORY   CANAL.  131 

as  when  done  with  the  scalpel.  The  ear  should  be  syringed 
with  warm  water  after  the  hemorrhage  has  ceased,  and  care- 
fully dried  with  the  cotton-holder,  or  the  impairment  of  hear- 
ing and  sensations  of  fulness  will  be  greater  than  before  the 
opening  was  made. 

After  the  furuncle  is  opened,  and  the  pain  caused  by  it  has 
disappeared,  it  is  well  to  smear  the  passage  with  some  oint- 
ment, in  order  to  hasten  the  softening  of  the  indurated  tissue 
surrounding  the  furuncle,  but  as  long  as  pain  continues  the 
use  of  warm  water  should  be  persisted  in  by  means  of  the 
aural  douche.  The  thorough  cleansing  will  usually  relieve 
the  impairment  of  hearing  caused  by  the  swelling  and  closure 
of  the  canal,  while  the  incision  and  douche  will  cut  short  the 
pain.  Each  new  furuncle  is  of  course  to  be  treated  in  the 
same  way.  Steam  may  also  be  allowed  to  pass  into  the  ear 
from  any  sort  of  a  vessel. 

Leeches  do  not  seem  to  do  the  same  amount  of  good  in 
furuncular  inflammation  as  in  the  diffuse  form. 

The  vapor  of  chloroform  passed  into  the  auditory  canal 
has  been  highly  spoken  of,  but  I  do  not  know  much  of  it  by 
experience,  having  been  generally  satisfied  with  the  method 
of  treatment  above  indicated. 

We  shall  probably  not  be  done  with  the  case  when  one 
furuncle  has  been  evacuated,  and  has  healed  ;  for  here  just  as 
in  other  parts  of  the  body,  one  boil  is  apt  to  follow  another 
in  rapid  succession. 

Causes. — This  brings  us  to  consider  the  cause  of  this  affec- 
tion. I  do  not  think  I  ever  saw  a  furuncular  inflammation  of 
the  external  auditory  canal  in  a  patient  who  was  in  other 
respects  in  a  physiological  condition.  It  seems  to  be  the 
evidence  of  a  wrong  state  of  the  system  of  some  kind. 

Furuncles  are  very  apt  to  occur  in  anaemic  persons.  I 
have  seen  several  cases  where  they  were  troublesome  after 
parturition,  during  which  the  system  had  been  much  ex- 
hausted, and  perhaps  the  patient  had  not  been  under  the 
most  judicious  management  as  regards  the  diet.  When  iron 
was  administered,  and  nourishing  diet  substituted  for  slops, 
the  boils  ceased  to  recur. 


132  FUBUNCLES   IN  THE  AUDITOEY   CANAL. 

Every  spring  I  see  cases  of  furuneular  inflammation  in 
young  ladies  who  were  zealous  attendants  upon  the  German, 
and  who  spent  large  portions  of  the  night  in  the  ball-room, 
for  quite  long  periods.  They  were  not  particularly  anaemic, 
but  they  had  no  proper  appetite,  and  were  evidently  suffering 
from  the  effects  of  an  improper  mode  of  life.  Regular  hours, 
regular  times  for  eating,  exercise  in  the  open  air,  soon  relieved 
these  cases,  but  those  who  would  persist  in  their  dissipations, 
did  not  recover  until  the  season  was  over.  In  one  case  there 
were  also  hordeoli  or  styes,  which  are  generally  regarded  as 
evidences  of  mal-nutrition. 

It  will  be  seen  from  this,  that  the  local  treatment  is  by  far 
the  lesser  part  of  our  labor  in  these  cases  of  circumscribed 
inflammation  of  the  auditory  canal.  We  should  be  very  care- 
ful to  inquire  as  to  the  appetite,  exercise,  mode  of  life,  and 
specifically  correct  anything  which  may  be  out  of  the  way.  It 
will  not  be  enough  to  give  general  directions,  such  as,  "  You 
must  take  exercise  and  live  well,"  but  the  amount  and  kind  of 
exercise,  the  time  of  eating,  variety  of  food,  and  so  on,  should 
be  plainly  indicated ;  at  the  same  time  some  one  of  the  prepa- 
rations of  iron  will  generally  be  required. 

The  ear  should  be  kept  from  the  influence  of  cold  air,  when 
the  patient  is  out  of  doors,  by  cotton,  or  an  ear-lap  ;  but  the 
habit  of  thus  protecting  the  ears  in  the  open  clear  air,  where 
there  is  no  draught,  should  be  abandoned  when  the  furuncles 
have  ceased  to  recur. 

Note.— I  have  lately  found,  after  the  suggestion  of  Dr.  L.  Fisher,  that  the 
use  of  a  small  cotton  plug  saturated  with  glycerine,  is  a  valuable  means  of 
relieving  the  pain  from  a  furuneular  inflammation  of  the  canal.  The  plug 
should  he  changed  twice  a  day. 


CHAPTER    VI. 

PARASITIC  INFLAMMATION  OF  THE  EXTERNAL  AUDITORY  CANAL. 


SYPHILITIC  ULCERS  AND   CONDYLOMATA. 

It  is  not  more  than  six  years  since  the  profession  became 
generally  aware  of  the  fact,  that  vegetable  fungi  were  germi- 
nated in  the  auditory  canal,  and  that  they  caused  or  aggravated 
inflammations  of  this  part  and  of  the  surface  of  the  membrana 
tympani.  By  the  publications  of  Professor  Schivartze  of  Halle, 
Br.  Wreden  of  St.  Petersburg,  and  many  others  whose  names 
will  be  quoted  in  this  chapter,  this  fact  has  now  become  well 
known,  and  has  enabled  us  to  more  clearly  understand  and 
more  successfully  treat  certain  cases  of  otitis  externa. 

The  history  of  the  growth  of  the  aspergillus  fungus,  as 
well  as  that  of  the  other  vegetable  parasites  that  have  been 
found  in  the  ear,  is  so  recent,  that  an  account  of  it  seems  to 
be  necessary  as  an  introduction  to  the  study  of  the  diseases 
caused  by  it. 

In  1867,  Schwartze*  reported  a  case  of  inflammation  of 
the  auditory  canal,  in  which  the  aspergillus  fungus  was  found. 
Prof.  J.  Vogel  made  the  microscopic  examination  that  settled 
the  fact,  and  he  called  Schwartze's  attention  to  two  cases 
which  had  been  previously  reported ;  one  by  Mayer  in  Mul- 
ler's  Archiv,  1844,  p.  401,  and  one  by  Pacini,  quoted  by 
Kuclienmeister  in  his  work  on  Parasites,  published  in  Leipzig 
in  1855.  In  both  these  cases  the  fungus  was  a  species  of 
aspergillus. 

Mayer's  case  was  peculiar.  The  fungus  occurred  in  the 
ear  of  a  child,  having  what  he  called  scrofulous  otorrhcea,  and 

*  ArcMv  fur  Olirenheilkunde,  Bd.  II,  p.  7. 


134  OTITIS  PARASITICA. 

the  parasite  was  contained  in  round  and  oval  cysts,  of  the  size 
of  a  cherry.  The  walls  of  the  cysts  were  fibrous,  filamentous, 
white  in  color  externally,  while  within  they  were  hollow, 
greenish  and  granular. 

Pacini's  case  was  like  those  that  have  since  been  observed : 

A  boy  of  fourteen  years  came  from  a  sea-bath,  and  complained  that  water 
remained  in  his  ear.  Itching  and  painful  sensations  ensued,  and  at  last  nearly 
complete  deafness.  In  the  auditory  canal  small  transparent  vesicles  were  seen. 
Two  weeks  after  a  whitish  membrane  was  found  on  the  walls.  It  was  removed 
by  syringing  with  warm  water ;  but  it  soon  returned.  The  microscopic  exam- 
ination revealed  the  presence  of  a  fungus.  The  parasite  was  removed  by  the 
injection  of  a  solution  of  acetate  of  lead,  of  the  strength  of  two  grains  to  the 
ounce  of  water. 

Dr.  Robert  "Wreden*  reported  six  cases  of  the  growth  of 
the  aspergillus  fungus  the  year  after  Schwartze's  case  was 
published.  He  gave  the  name  of  myringomykosis  to  the  dis- 
ease caused  by  the  fungus.  He  subsequently  added  eight  to 
these,  and  published  the  whole,  with  a  very  complete  account 
of  the  appearance  of  the  fungus,  in  a  monograph. t 

Since  the  publication  of  Schwartze's  and  Wreden's  cases 
others  have  been  reported  b^  Orne  Green,!  of  Boston,  C.  J. 
Blake,  Knapp,  and  by  myself  §  and  others.  Indeed,  the  occur- 
rence of  such  a  fuDgus  in  an  inflamed  ear  is  now  a  well  recog- 
nized fact,  for  which  we  are  indebted  to  Schwartze. 

Causes. — In  order  that  we  may  correctly  understand  the  na- 
ture of  parasitic  otitis,  it  should  be  remembered  that  it  is  not  a 
primary  disease,  but  a  consequence  of  a  diffuse  otitis,  which 
may  have  been  of  such  a  mild  character  as  scarcely  to  have 
attracted  the  attention  of  a  patient,  especially  if  it  occur  in 
one  who  is  taught  to  believe,  as  most  patients  are,  that  an 
aural  disease  will  "  wear  away  "  of  itself,  or,  at  any  rate,  that 
medical  assistance  will  be  of  no  avail  for  it. 

The  disease  which  usually  precedes  the  formation  of  a 
vegetable  fungus  in  the  ear,  is  usually,  as  I  believe,  an  eczema. 

The  etiology  of  the  affection  is  not,  however,  quite  clear, 

*  Archiv  fur  Ohrenheilkunde,  B.  III.,  p.  1. 
f  Die  Myringomykosis  aspergillina.     St.  Petersburg. 
X  Transactions  of  the  American  Otological  Society,  1869. 
§  American  Journal  of  the  Medical  Sciences,  Jan.,  1870. 


OTITIS  PARASITICA.  135 

but  I  feel  quite  certain  that  I  have  not  seen  a  case  of  the 
growth  of  the  vegetable  fungus  in  which  the  ear  was  sound 
before  the  growth  occurred.  Some  kind  of  an  inflammation 
which  loosens  the  epidermis,  has  first  occurred. 

The  fungus  is  actually  a  mould,  such  as  clings  to  damp 
walls  and  adheres  to  bread  that  is  not  kept  thoroughly 
dry.  As  we  should  expect,  the  habits  of  the  Eussians,  living, 
as  they  are  almost  compelled  to,  in  badly  ventilated  rooms 
during  the  long  winter,  are  very  favorable  to  the  production 
of  aspergillus. 

There  is  hardly  a  doubt  that  these  cases  of  vegetable  fun- 
gous growths  in  the  ear,  were  formerly  mistaken  for  impacted 
cerumen,  and  otitis  externa  diffusa.  Since  my  attention  has 
been  called  to  the  subject,  I  recall  two  cases  of  very  obstinate 
inflammation  of  the  auditory  canal,  which  I  now  believe  were 
cases  of  the  growth  of  vegetable  parasites  in  the  part.  It  is 
an  interesting  fact,  that  they  both  recovered  from  the  affec- 
tion without  any  use  of  the  specific  parasiticides. 

Symptoms. — The  subjective  symptoms  of  the  growth  of  a 
vegetable  fungus  in  the  ear,  are  very  similar  to  those  from 
inspissated  cerumen.  There  is  a  sensation  of  fulness  in  the  ear, 
with  tinnitus  aurium,  vertigo,  impairment  of  hearing,  and  pain. 

As  is  well  known,  pain  is  not  a  common  symptom  of  inspis- 
sated cerumen,  although  it  does  occur.  Pain  is,  however, 
usually  one  of  the  symptoms  of  otitis  parasitica.  It  is  not, 
however,  the  severe  pain  of  a  furuncle,  or  of  acute  catarrh 
of  the  middle  ear,  but  it  is  a  dull,  heavy  sensation  in  the  ear. 

The  objective  symptoms  consist  in  the  adherence  to  the 
walls  of  the  canal  and  to  the  outer  surface  of  the  membrana 
tympani  of  whitish  or  blackish  flakes,  that  may  be  readily 
mistaken  for  simple  epidermis  or  hard  wax.  Sometimes  these 
flakes  or  casts  block  up  the  whole  passage.  They  cannot  be 
removed  by  a  syringe  ;  but  the  angular  forceps,  which  should 
only  be  used  under  a  good  illumination  by  means  of  the  oto- 
scope, are  required  to  detach  them.  When  the  casts  are 
removed  the  tissue  beneath  is  found  to  be  reddened  and  ten- 
der, and  in  a  very  few  hours  the  growth  will  be  found  to  be 
reproduced. 


136  OTITIS   PARASITICA. 

The  microscope  must  be  called  in  to  make  the  diagnosis 
certain.  The  appearance  of  the  growth,  as  seen  by  the  aid 
of  this  instrument,  -will  soon  be  detailed. 

The  practitioner  who  has  once  carefully  observed  the 
objective  evidences  of  a  vegetable  fungus  will,  however,  not 
be  apt  to  fail  to  recognize  it  in  a  subsequent  case. 

The  varieties  of  vegetable  parasites  that  may  be  found  in 
the  ear,  and  which  there  cause  inflammation,  are 

( flavus, 
I. — Aspergillus  -<  glaucus, 

'  nigricans. 
II. — Penicillium  glaucum. 
III. — Graphium  pencilloides. 
IV. — Trichothecium  roseum. 

The  aspergillus  fungus,  which,  in  one  of  its  varieties,  is  the 
parasite  most  commonly  found  in  the  ear,  se'ems  to  have  a  pecu- 
liar affinity  for  a  diseased  auditory  canal  and  membrana  tym- 
pani,  and  to  be  found  almost  exclusively  on  this  part  of  the 
body.  Dr.  William  H.  Draper,  of  this  city,  has,  however, 
observed  one  case  of  the  growth  of  the  aspergillus  fungus  on 
the  inner  side  of  the  thigh,  and  it  afterwards  appeared  in 
the  auditory  canal. 

"Wreden  was  not  able  to  find  any  penicillium  fungus  in  his 
cases,  but  Blake  *  reports  a  case  in  which  on  the  second  attack 
of  otitis  parasitica,  specimens  of  bastard  penicillium  were  found. 

Dr.  Hassenstein,\  of  Gotha,  has  observed  one  case  in  which 
a  patient  suffering  from  the  usual  symptoms  of  aural  catarrh 
was  found  to  have  a  3-ellowish  green  secretion  upon  the  mem- 
brana tympani.  This  secretion  continued  for  some  ten  days, 
in  spite  of  treatment,  and  there  was  considerable  redness, 
swelling,  and  pain  in  the  auditory  canal  and  drum-head. 

This  secretion  was  found  to  contain  three  varieties  of 
vegetable  fungi,  as  an  examination  by  Professor  Hallier,  of 
Jena,  showed  :  1.  Aspergillus  glaucus.  2.  Stemphylium,  which 
was  very  like  stemphylium   polomorphum  belonging  to  the 

*  Transactions  American  Otological  Society,  fourth  year,  1871. 
\  Arcliiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  164. 


OTITIS   PAEASITICA.  137 

aspergillus.  3.  Graphium  pencilloides.  Dr.  Hallier  was  un- 
able to  say  whether  the  second  variety  sprang  directly  from 
the  aspergillus  or  not.  The  graphium  pencilloides,  of  which 
an  accurate  botanical  description  is  given  in  the  article  from 
which  I  am  quoting,  occurs  in  nature  on  wood,  especially  on 
elder-wood. 

Dr.  F.  Sleudener*  of  Halle,  describes  another  form  of 
fungus  which  occurs  in  the  ear,  Trichothecium  roseum.  The 
evidence  on  this  point  is  not  quite  conclusive,  however,  for 
Professor  de  Barry,  to  whom  Dr.  S.  showed  the  specimen, 
said  it  resembled  this  fungus,  although  it  could  not  be  tho- 
roughly examined,  the  specimen  having  been  injured.  Dr. 
Steudener  then  cultivated  the  actual  trichothecium  fungus 

Fig.  34. 


Aspergillus  nigricans.    220  Diameters. 

a.  Mxjcelium  fibre,    b.  Fruit-bearing  fibre,    c.  Naked  sporangium,    d.  Sporangium  covered 
ivitk  basidia  only.    e.  More  mature  sporangium,    i.  Spores  in  a  state  of  germination. 

upon  some  epidermis,  and  inasmuch  as  the  spores  and  myce- 
lium resembled  those  in  the  fungus  removed  from  the  ear,  he 
thought  himself  justified  in  assuming  that  the  latter  were  actu- 
ally those  of  the  trichothecium  roseum.  The  evidence  is  there- 
fore not  quite  positive  as  to  the  nature  of  the  fungus. 

*  Archiv  fur  OhrenlieOkunde,  B.  V.,  p.  163. 


138  OTITIS  PAKASITICA. 

The  different  varieties  of  the  aspergillus  fungus  are  by  far 
the  common  kinds  of  vegetable  parasites  that  have  been  found 
in  the  ear,  although  it  is  probable,  now  that  attention  has 
been  turned  to  this  subject,  that  others  will  be  found. 

The  first  two  of  the  accompanying  drawings  of  the  asper- 
gillus were  made  by  my  friend,  Dr.  "William  B.  Lewis,*  from 
specimens  of  cases  occurring  in  my  practice.  The  third  engrav- 
ing (Fig.  36)  represents  another  specimen  from  the  same  source, 
which  was  drawn  by  my  colleague,  Dr.  Charles  S.  Bull.  Dr. 
Lewis  describes  the  fungus  as  of  three  essential  parts  : 

1st,  the  mycelium,  a  dense  network  or  pseudo-membrane 
of  delicate  fibres,  which  form  the  groundwork  or  roots,  as  it 
were,  from  which  the  2d  part,  or  fructifying  portion  (fertile 
hyphen),  arises  perpendicularly ;  and  3d,  the  free  spores, 
which  he  thickly  strewn  upon  and  in  the  mycelium. 

Fig.  35. 


'wM 


Aspergillus  fiavescens.    220  Diameters. 

a.  Mycelium  fibre,    b.  Fruit-bearing  fibre,    c.  Sporangium-bearing  spores  upon  the  basidia. 
g,  Basidia,  showing  constriction  preparatory  to  the  separation  of  spores,    k.  Epithelium. 

The  physiological  relation  of  the  fruitful  fibres  to  the  mycelium  is  not 
shown  in  the  accompanying  cuts,  but  may  be  at  once  made  clear  by  examining 
a  portion  of  common  mould  with  low  power. 

The  fibres  of  the  pseudo-membrane  are  unfruitful,  branched,  straight,  or 
curved,  and  frequently  somewhat  swollen  at  the  joints.  In  the  broader  fibres 
transverse  cell-walls  are  distinguished,  and  all,  broad  and  narrow,  contain 
faintly  granular  plasma.  The  breadth  of  the  mycelium  fibres  was  from  0.00015 
to  0.0002  of  an  inch  (0.0038  to  0.005  of  a  millimetre). 

In  the  fruit-bearing  portion  are  found  the  changes  in  form  which  establish 

*  American  Journal  of  the  Medical  Sciences,  Jan.,  1858. 


OTITIS  PAEASITICA. 


139 


the  varieties.  It  consists  of  a  filament,  which,  especially  in  the  aspergillus 
nigricans,  is  stouter  than  those  of  the  mycelium,  bearing  upon  its  summit  an 
enlargement,  the  receptacle  or  sporangium. 

Those  who  are  interested  in  a  fuller  botanical  description  of  the  fungus  will 
find  it  in  the  journal  from  which  I  have  quoted,  as  given  by  Dr.  Lewis,  in  an 
article  furnished  by  Dr.  L.  and  myself,  and  in  Wreden's  monograph. 

Fig.  36. 


Specimen  of  the  Spores  and  fully  developed  Growth  of  the  Aspergillus  flavescens.    Case  III. 


In  Dr.  Blake's  case,  which  has  been  alluded  to,  a  portion 
of  the  specimen  was  planted  upon  lemon-peel,  placed  in  a 
closed  glass  vessel,  at  a  constant  temperature  of  80°  F.,  when 
it  gave,  at  the  end  of  the  third  day,  a  well-developed  growth 
of  the  Leptothrix  form  of  Penicillium. 


140 


OTITIS  PAEASITICA. 


Fig.  37. 


The  specimen  represented  in  the  accompanying  wood-cut 
exhibited  a  mycelium  and  fully  developed  sporangia  (a).     The 

spores,  of  which  a  collection  is  re- 
presented at  b,  were  of  a  brown  color 
and  oval  outline,  of  about  the  same 
size  as  the  spores  of  Aspergillus  ni- 
gricans. Under  a  magnifying  power 
of  300,  some  of  these  spores  showed 
a  double  outline.  Mingled  with  this 
growth  there  was  a  close  network  of 


PenicUlium.    After  Blake. 


very  fine  mycelium. 


Treatment. — The  treatment  of  otitis  parasitica  is  exceed- 
ingly simple,  but  it  is  often  very  tedious,  and  the  practitioner 
must  not  expect  that  all  the  aural  symptoms  will  be  relieved 
when  the  vegetable  fungus  has  ceased  to  appear.  If  the 
theory  which  I  have  adopted,  that  the  parasitic  affection  is  a 
secondary  disease,  be  correct,  we  may  only  expect  to  relieve  the 
most  troublesome  symptoms,  pain,  vertigo  and  impairment  of 
hearing,  by  the  destruction  of  the  parasite.  The  inflammation 
will  continue,  in  some  cases,  long  after  the  microscope  has 
failed  to  find  any  traces  of  aspergillus  in  the  auditory  canal. 

But  the  loosened  epidermis  and  the  flakes  of  mould  should 
be  carefully  removed  every  day  by  means  of  the  forceps  and 
syringe,  the  ear  being  well  illuminated  while  the  former  is 
used,  and  the  canal  frequently  douched  with  warm  water  by 
means  of  Clarke's  douche.  I  am  in  the  habit  of  pencilling 
the  canal  with  nitrate  of  silver  in  strong  solutions,  after  the 
cleansing  process  is  over,  not  for  the  purpose  of  destroying 
the  fungus,  but  to  subdue  the  inflammation  of  the  integument. 
At  the  same  time,  I  treat  any  affection  of  the  middle  ear,  that 
may  co-exist  with  that  of  the  canal,  by  the  appropriate  means. 

Dr.  "Wreden  gives  a  long  list  of  agents  which  he  believes 
to  be  useful  as  parasiticides.  He  mentions,  among  others, 
alcohol,  bichloride  of  mercury,  acetate  of  lead,  tincture  of 
iodine  and  carbolic  acid.  He  prefers  the  hypochlorate  of 
lime,  which  he  recommends  to  be  used  in  the  strength  of  one 
to  two  grains  to  the  ounce  of  water.  The  salt  must  be  freshly 
dissolved  in  water  at  each  application.     Fowler's   solution 


OTITIS  PARASITICA.  141 

ranks  next  to  the  lime  as  a  parasiticide,  according  to  Wreden. 
Solutions  of  tannic  acid,  gr.  x  ad  §  j,  are  used  by  some  author- 
ities. 

Drs.  Orne  Green  of  Boston,  and  Knapp  of  this  city,  concur 
with  me  in  believing  that  a  thorough  use  of  warm  water  is  the 
only  parasiticide  necessary. 

Dr.  Eugene  Peuguet,*  of  this  city,  believes  from  experience 
in  one  very  obstinate  case,  that  the  following  formula  is  very 
useful. 

R.    Veratria gr.  ij 

Acid.  Acet m.  x 

Aq.  Rosa)aa>  ,sg_ 
Glycerine ) 

This  is  to  be  pencilled  on  the  ear  after  the  canal  is  thor- 
oughly cleansed.     I  have  used  this  formula  but  in  one  case. 

The  following  cases  will  furnish  a  commentary  on  what  has 
been  said,  and  perhaps  illustrate  the  nature  of  the  affection 
better  than  any  more  extended  remarks.  The  first  two  have 
already  been  published,!  but  the  third  has  never  before  been 
printed. 

CASES  OF  ASPERGILLUS. 

Case  I. — I  was  consulted,  June  80,  1869,  by  J.  F.  B.,  a  gentleman  aet.  24,  in 
regard  to  pain  and  impairment  of  hearing  in  the  left  ear.  He  stated  that 
about  a  year  before  he  had  experienced  a  sense  of  fulness  in  the  ear,  as  if  it 
were  "  stopped  up,"  and  that,  at  the  same  time,  there  was  considerable  tinnitus 
aurium.  He  consulted  a  physician,  who  diagnosticated  inspissated  cerumen, 
and  removed  a  large  quantity  of  what  seemed  to  be  ear-wax  from  the  canal. 
The  relief  afforded  was  of  short  duration,  for  the  ear  soon  filled  up.  From 
that  time  to  the  present  the  patient  has  been  in  the  habit  of  syringing  the  ear, 
and  at  times  masses  of  some  foreign  substance  were  removed  by  this  process. 
Of  late  he  has  noticed  black  particles  strewn  in  the  substance  removed,  which 
he  thinks  are  due  to  the  entrance  of  dust  from  the  smoke-pipe  of  a  steamer 
during  a  recent  voyage  from  Europe.  The  patient  now  experiences  very  con- 
siderable pain  in  the  ear,  and  it  is  the  occurrence  of  this  new  symptom  which 
has  led  him  to  consult  me.  The  other  symptoms — the  sensation  of  fulness, 
tinnitus  aurium,  and  impaired  hearing,  continue.  Patient's  general  health  is 
good,  though  he  is  very  subject  to  naso-pharyngeal  catarrh. 

*  American  Journal  of  Syphilography  and  Dermatology,  vol.  iii,  p.  209. 
f  American  Journal  of  the  Medical  Sciences,  1.  c. 


142  CASES  OF  ASPERGILLUS. 

On  examination,  a  watch  which  is  usually  heard  at  least  thirty  inches 
from  the  auricle  is  only  heard  one  and  a  half  inches,  and  the  auditory  canal 
is  filled  with  a  lardaceous  mass,  punctated  by  minute  black  spots.  This 
mass  was  very  adherent  to  the  walls  of  the  canal,  and  could  not  be  thor- 
oughly removed  by  syringing,  but  required  the  use  of  the  angular  forceps, 
under  a  good  illumination  by  means  of  Troltsch's  otoscope  and  ordinary 
daylight.  The  surface  beneath  this  mass,  which  peeled  off  from  the  canal,  was 
red  and  very  sensitive.  After  the  removal  of  the  foreign  substance,  a  minute 
perforation  of  the  membrana  tympani  was  found  situated  in  the  anterior  and 
inferior  quadrant.  There  was  no  true  suppuration,  but  mucus  alone  bubbled 
out  from  the  opening  during  the  inflation  of  the  Eustachian  tube.  The  Eusta- 
chian tube  was  shown  to  be  permeable  by  Politzer's  method,  but  there  was 
very  little  sensation  experienced  in  the  ear  when  the  air  was  forced  in. 

On  the  removal  of  the  collection,  the  patient  experienced  immediate  relief 
from  the  pain  and  tinnitus  aurium,  but  the  hearing  was  not  very  much  im- 
proved. The  diagnosis  catarrh  of  the  middle  ear  was  made,  while  an  exact 
definition  of  the  state  of  things  in  the  canal  was  delayed.  Portions  of  the 
lardaceous,  flaky  substance  removed  from  the  canal  were  placed  in  glycerine. 

He  was  ordered  to  use  injections  of  warm  water,  by  means  of  Clarke's  aural 
douche,  several  times  daily,  and  to  drop  in  a  solution  of  zinc,  sulph.,  gr.  ij  ad 
aqua  3  j,  twice  a  day.  The  Eustachian  catheter  was  used,  and  air  injected 
through  it  into  the  cavity  of  the  tympanum. 

It  was  some  days  before  the  entire  collection  was  fully  removed,  and  in 
spots  where  it  had  been  separated  and  taken  out,  it  was  renewed  very  rapidly, 
and  each  time  reproduced  the  symptoms  of  pain  and  fulness.  A  -weak  solution 
of  carbolic  acid  was  then  used  ;  but  it  caused  very  great  irritation,  and  inflam- 
mation was  set  up,  which  lasted  many  days.  This  was  treated  by  the  use  of 
warm  water,  through  the  douche.  When  it  had  subsided,  the  lardaceous 
masses  were  removed  by  the  forceps,  and  in  some  instances  casts  of  the  mem- 
brana tympani  came  away,  although  the  walls  of  the  canal  showed  the  most 
disposition  to  a  reproduction  of  the  growth. 

July  27,  the  opening  in  the  membrana  tympani  had  healed,  and  the  hear- 
ing so  much  improved  that  the  watch  was  heard  six  inches,  and  the  symptoms 
completely  relieved.  There  was  still  a  slight  tendency  to  the  growth  of  the 
fungus,  as  it  proved  to  be,  on  the  posterior  wall  of  the  canal.  The  membrana 
tympani  was  lustreless  and  rigid,  the  handle  of  the  malleus  distinct,  but  there 
was  no  light  spot.  From  the  1st  of  August  I  did  not  again  see  my  patient 
until  October  18th.  Meanwhile  he  had  used  the  aural  douche  daily,  and  the 
growth  had  not  returned  ;  but  the  catarrhal  inflammation  of  the  middle  ear 
had  not  been  materially  benefited,  as  shown  by  the  rigidity  of  the  membrana 
tympani  and  the  impairment  of  hearing.  The  membrane  is  now  (November 
19)  somewhat  translucent,  and  the  patient  is  being  treated,  with  benefit,  by 
means  of  the  injection  of  air,  the  use  of  a  gargle,  etc.,  for  the  middle  ear 
affection. 

The  flakes,  preserved  in  glycerine,  were  examined  by  my  friend  Dr.  C.  E. 
Hackley  and  myself  under  the  microscope,  and  Dr.  Hackley  believed  them  to 
exhibit  specimens  of  Aspergillus  nigricans.  At  a  later  date,  Dr.  Wm.  B.  Lewis 
very  kindly  made  a  thorough  examination,  and  confirmed  Dr.  Hackley's  opin- 


CASES  OF  ASPEKG1LLUS.  143 

ion.  In  this  case  it  is  clearly  evident  that  the  growth  of  the  fungus  was 
secondary  to  the  inflammation  of  the  middle  ear,  for  the  patient  never  fully 
recovered  his  hearing  power. 

Case  II. — Sept.  28,  1869, 1  was  consulted  by  Mr.  S.,  set.  51,  on  account  of 
impaired  hearing,  vertigo,  pain  in  the  ears,  and  tinnitus  aurium.  Vertigo  was 
the  symptom  upon  which  the  patient  laid  the  most  stress,  and  of  which  he 
was  most  anxious  to  he  relieved.  He  said  that  he  was  so  dizzy  whenever  he 
attempted  to  walk  about,  as  to  be  unable  to  attend  to  his  ordinary  business.  His 
condition  in  other  respects  was  excellent.  The  patient  also  stated  he  had  heard 
perfectly  well  until  two  months  since,  when  he  was  attacked  with  the  aural 
symptoms  narrated  above,  which  had  been  aggravated  since  their  inception. 
He  had  been  treated  by  the  instillation  of  oils,  and  so  on.  He  could  hear  my 
watch  about  one  inch  on  the  right  side,  and  not  at  all  on  the  other.  Both 
auditory  canals  were  found  filled  with  a  tenaceous  material,  which  could  only 
be  removed  by  the  forceps.  It  was  several  days  before  I  could  completely 
remove  the  firmly  adherent  coating  of  the  canal  and  membrana  tympani. 

The  morbid  product  was  immediately  examined  by  Dr.  Lewis,  and  found 
to  be  a  specimen  of  the  Aspergillus  flavescens.  Its  removal  gave  the  patient 
great  relief ;  but  on  the  reappearance  of  the  growth,  which  was  in  two  or  three 
days  after  its  thorough  removal,  the  vertigo  and  tinnitus  returned.  The  mem- 
brana tympani  was  intact,  but  lustreless  and  rigid.  The  Eustachian  tubes 
opened  sluggishly,  and  there  was  all  the  evidence  of  aural  catarrh,  beside  the 
affection  of  the  canal  and  of  the  outer  layer  of  the  membrane  of  the  tympanum. 
The  free  use  of  warm  water,  with  an  astringent,  finally  subdued  the  morbid 
process  in  the  canal,  so  that  the  patient  was  able  to  make  a  journey  to  the 
South.  When  he  left  my  care,  Oct.  18,  the  auditory  canals  were  entirely  free 
from  abnormal  secretion,  the  hearing  was  improved,  so  that  the  watch  was 
heard  from  five  to  six  inches  on  the  right  side,  and  from  one  to  two  on  the 
left.  The  dizziness  was  entirely  gone,  and  the  tinnitus  ceased  to  be  annoying. 
The  catarrh  of  the  inside  ear,  as  shown  by  rigidity  of  the  membrana  tympani, 
sluggish  action  of  the  tubes,  and  impairment  of  hearing,  still  continued.  I 
saw  this  patient  about  a  year  afterward,  and  he  was  entirely  well,  his  ears 
having  returned  to  a  normal  condition. 

Case  III— Lt.  L.,  ast.  30,  IT.  S.  N.— Dec.  2,  1872— Since  a  child,  has  been 
more  or  less  deaf  in  right  ear,  owing  to  a  series  of  abscesses.  This  impairment 
of  hearing  was  increased  by  his  service  near  the  frequent  explosion  of  caunon. 
About  a  year  ago  he  had  an  abscess  in  left  ear  (probably  in  auditory  canal), 
with  considerable  purulent  discharge  having  an  offensive  odor.  For  about 
two  weeks  he  has  had  a  series  of  abscesses  in  the  left  ear,  with  considerable 
discharge  of  black  material. 

Hearing  distance,  R.  -4a8-,  L.  -4%. 

The  tuning-fork  was  heard  more  distinctly  in  the  right  ear  when  the  han- 
dle was  placed  on  the  forehead  or  teeth.     The  pharynx  is  granular. 

The  right  membrana  tympani  is  very  much  sunken  and  is  opaque. 

The  auditory  canal  of  that  side  contains  numerous  scales  of  epidermis 
strewn  with  black  spots. 


144  SYPHILITIC   ULCERS  AND   CONDYLOMATA. 

The  left  canal  is  full  of  pus,  and  the  menibrana  tympani  is  perforated. 

The  microscopic  examination  showed  the  presence  of  the  aspergillus  nigri- 
cans in  both  auditory  canals. 

The  patient's  general  condition  was  excellent,  except,  as  is  the  case  with  most 
aural  patients,  he  was  somewhat  despondent  on  account  of  the  loss  of  hearing. 

The  diagnosis  of  chronic  suppurative  inflammation  of  the  middle  ear,  with 
aspergillus  growth,  was  made  as  regards  the  left  ear.  In  the  right,  there  was 
chronic  non-suppurative  inflammation  with  the  same  fungus  growth  in  the 
auditory  canal. 

The  patient  was  seen  nearly  every  day  until  December  24,  and  treated  by 
the  use  of  leeches,  the  syringe  and  warm  water,  with  the  subsequent  applica- 
tion of  nitrate  of  silver,  gr.  40  ad  §  j,  brushed  over  the  canal  and  drum-head. 
The  patient  also  caused  his  ears  to  be  syringed  at  home,  and  instilled  a  solu- 
tion of  sulphate  of  zinc,  two  grains  to  the  ounce,  into  the  ears.  The  Eusta- 
chian catheter  and  Politzer's  method  were  used  to  force  air  into  the  middle 
ears,  and  the  patient  used  a  gargle  of  chlorate  of  potash. 

The  aspergillus  fungus  disappeared  in  a  few  days,  but  the  affection  of  the 
middle  ear  and  canal  lasted  much  longer. 

On  the  24th  of  December,  however,  just  22  days  after  he  came  under 

Ql_  jQ 

treatment,  Lt.  L.  was  discharged,  with  hearing  distance  for  watch,  R.  -r|,  L.  — . 

At  16  feet  distance  he  could  hear  and  carry  on  a  conversation  in  the  ordinary 
tone,  with  his  face  away  from  the  speaker.  The  left  canal  still  continued  to 
swell,  and  the  epidermis  to  scale  off.  The  patient  had  eczema  of  the  scalp  and 
auricle.     Some  weeks  after  he  was  said  to  be  still  improved. 


SYPHILITIC  ULCERS.     CONDYLOMATA. 

I  have  not  seen  affections  of  the  auditory  canal  which 
could  be  said  to  be  the  result  of  the  poison  of  syphilis ;  but 
trustworthy  authors*  speak  of  secondary  syphilitic  ulcerations 
of  the  auditory  canal,  and  of  condylomata  f  occurring  in  the 
same  part.  Schwartze  believes  that  polypoid  growths  in  the 
canal  are  sometimes  a  local  manifestation  of  syphilis.  Inas- 
much, however,  as  granulations  exactly  like  those  occurring 
in  syphilitic  cases  are  also  found  in  the  auditory  canals  of 
persons  not  affected  with  syphilis,  it  becomes  very  difficult  to 
say  that  such  growths  are  ever  pathognomonic  of  the  disease. 
This  much  is  certain,  syphilitic  affections  of  the  auditory  canal 
are  extremely  rare,  while  it  cannot  be  denied  that  the  poison 
of  syphilis  once  in  the  system  will  modify  any  affection  that 
may  occur  in  any  of  the  organs  of  the  body. 

*  Schwartze,  Archiv  fur  Ohrenheilkunde,  Bd.  IV,  p.  262. 
f  Steudener,  1.  c,  Bd.  IV,  p.  20. 


SYPHILITIC   ULCERS  AND   CONDYLOMATA.  145 

I  will,  however,  reserve  the  discussion  of  the  effects  of 
syphilis  upon  the  ear,  for  a  fuller  treatment  in  a  later  chapter. 

I  need  only  further  say,  at  this  point,  that  whether  ulcera- 
tions or  growths  in  the  auditory  canal  be  or  be  not  caused  or 
modified  by  syphilis,  the  necessity  for  local  treatment — at  the 
basis  of  which  is  local  cleanliness — remains  as  urgent  as  if 
there  were  no  constitutional  disease. 

The  most  appropriate  constitutional  treatment  can  never 
do  away  with  the  necessity  for  local  care. 


CHAPTER    VII. 

INSPISSATED    CERUMEN. 

Among  tlie  laity,  and  even  in  the  profession,  hardening  of 
the  ear-wax  is  generally  regarded  as  a  very  harmless  affection. 
It  is  also  considered  by  many  as  the  most  common  of  all  the 
diseases  of  the  ear.  The  first  treatment  that  many  aural 
patients  receive  at  the  hands  of  their  medical  advisers,  is  a 
vigorous  syringing,  or  worse  still,  probing,  in  order  to  see  if 
the  wax  be  not  hardened. 

Now  the  facts  are,  that  inspissation  of  cerumen  is,  com- 
paratively, not  one  of  the  common  affections  of  the  ear,  and 
that  when  it  does  actually  occur,  it  is  by  no  means  the  simple 
and  harmless  disease  that  it  is  often  supposed  to  be.  Of  four- 
teen hundred  and  forty-eight  aural  cases  observed  by  myself 
in  private  practice,  only  one  hundred  and  one  were  what  might 
fairly  be  said  to  be  cases  of  inspissated  cerumen ;  that  is  to 
say,  cases  in  which  the  impaction  of  ear-wax  was  the  chief 
cause  of  the  aural  symptoms. 

It  would  be  manifestly  incorrect  to  clask  cases  of  chronic 
ulceration  of  the  middle  ear,  or  cases  of  chronic  non-suppura- 
tive  inflammation  of  the  same  part,  in  which  impacted  ceru- 
men was  also  found,  as  cases  of  the  last  named  disease. 

My  classification  is  founded  on  the  principle  that,  the 
hardening  of  the  secretion  is  not  in  any  fair  sense  a  primary 
or  independent  disease,  where  there  is  no  positive  relief  either 
from  the  tinnitus  aurium  or  impairment  of  hearing  by  the  re- 
moval of  the  cerumen.  It  is  possible  that  we  shall  some  day 
come  to  believe  that  inspissated  cerumen  is  very  rarely,  if 
ever,  an  independent  affection,  but  rather  a  symptom  of  some 
disturbance  of  the  nutrition  of  other  parts  of  the  organ  of 
hearing  than  the  auditory  canal ;  or,  perhaps,  that  it  is  due 


INSPISSATED   CERUMEN.  147 

to  the  mechanical  closure  of  the  canal  by  mechanical  swelling. 
Admitting,  however,  that  inspissated  cerumen  is  a  primary 
affection,  the  cases  which  have  been  alluded  to  should  be 
omitted  from  any  table  prepared  to  show  its  etiology. 

Toynbee  tabulated  200  cases  of  inspissated  cerumen ;  but  if 
the  above  ideas  be  correct,  many  of  his  cases  should  not  have 
been  classified  as  cases  of  hardening  of  the  ear  wax.  For  the 
same  reason  the  tables  of  many  Eye  and  Ear  Hospitals  are 
open  to  criticism. 

Symptoms. — The  prominent  symptoms  of  true  cases  of 
inspissated  cerumen  are — 

1.  Sudden  impairment  of  hearing. 

2.  Tinnitus  aurium. 

3.  Vertigo. 

4.  Pain  in  the  ear. 

The  practitioner  will  not  need  to  spend  much  time  in 
determining  the  cause  of  such  symptoms.  If  they  be  produced 
by  impaction  of  the  cerumen,  a  glance  at  the  auditory  canal 
by  means  of  the  speculum  and  otoscope  will  determine  the 
matter,  or  at  least  it  will  give  us  positive  evidence  as  to  the 
presence  of  the  inspissated  substance.  It  need  hardly  be  said 
that  the  practice  of  probing  the  ear  to  determine  if  the  wax 
be  hardened,  is  an  extremely  unphilosophical  procedure,  while 
it  is  not  without  danger  to  the  membrana  tympani.  .1  am 
obliged  to  say,  however,  that  I  have  seen  several  cases  in 
which  this  probing  has  been  undertaken  without  ocular 
examination ;  and  where  inflammation  of  the  lining  of  the 
canal,  of  the  drum-head,  and  in  one  case  even  perforation 
of  the  membrane,  had  resulted  from  the  manipulations  in 
the  dark. 

The  appearance  of  inspissated  cerumen  is  very  character- 
istic. Wax  which  presses  upon  the  walls  of  the  canal  and 
upon  the  membrana  tympani,  in  adults,  is  of  a  dark  brown  or 
black  color,  and  usually  fills  the  canal.  The  presence  of  even 
quite  an  amount  of  soft  yellow  cerumen,  which  still  leaves  an 
opening,  however  narrow,  down  to  the  drum-head,  can  hardly 
cause   any  unpleasant  symptoms. 

The  diagnosis  of  inspissated  cerumen  is  sometimes  ob- 


148  INSPISSATED   CERUMEN. 

scured,  by  the  useless  liabit  indulged  in  by  so  many  of  the 
laity  and. of  the  profession  also,  of  pouring  sweet  or  other  oils 
into  the  auditory  canal  on  the  appearance  of  any  aural  symp- 
toms. A  lady  once  came  from  St.  Louis  to  consult  a  New 
York  physician  in  regard  to  a  loss  of  hearing.  She  had  been 
seen  by  no  less  than  six  medical  men,  all  of  whom  had  pre- 
scribed applications  to  be  dropped  into  the  ear,  and  none  of 
whom  had  made  an  examination.  She  had  suffered  for  six 
years  from  the  great  impairment  of  hearing,  and  came  to  New 
York  as  a  last  resort.  Having  arrived  here,  she  was  sent  to 
me.  I  found  the  ears  filled  with  oils,  but  beneath  all  this, 
hardened  cerumen,  which  was  easily  removed  ;  and,  although 
her  hearing  had  been  impaired  for  so  long  a  time,  the  removal 
of  the  wax  restored  it  to  the  normal  power,  so  that  she  heard 
ordinary  conversation  with  ease,  and  a  watch  several  feet. 
In  this  case,  I  did  not  imagine,  until  the  ears  were  cleansed  by 
the  syringe,  that  impacted  cerumen  was  the  cause  of  the  loss  of 
hearing.  I  could  scarcely  believe  that  oils  would  be  persis- 
tently dropped  in  an  ear  by  so  many  different  advisers  before 
the  membrana  tympani  had  been  examined. 

The  tuning-fork  will  be  of  use,  if  the  inspissated  cerumen 
be  confined  to  one  side  in  determining  the  prognosis  ;  but 
practically  the  better  plan  is  to  defer  any  statement  as  to  the 
prognosis  until  the  cerumen  is  removed. 

The  loss  of  hearing  from  hardening  of  the  cerumen,  as  has 
been  intimated,  is  apt  to  occur  very  suddenly.  I  have  seen 
several  cases  where  patients  could  tell  the  very  instant  when 
the  ear  "  closed  up,"  as  they  often  say.  The  jolting  of  a  ride 
in  a  New  York  stage  often  displaces  the  hardened  material, 
and  presses  it  into  the  canal,  causing  troublesome  symptoms 
in  an  instant;  and,  as  I  have  said,  these  symptoms  do  not 
occur,  no  matter  how  much  cerumen  may  be  in  the  ear,  until 
the  impaction  takes  place,  when  the  loss  of  hearing,  the  tinni- 
tus aurium,  and  the  increased  resonance  of  the  patient's  own 
voice,  calls  his  attention  to  the  ear. 

Pain  of  the  most  distressing  nature  sometimes  occurs  from 
the  impaction  of  cerumen.  I  remember  one  case  where  ano- 
dynes had  been  used  for  ten  days  to  relieve  a  pain  in  the  ear, 
which  an  examination  showed  was  the  result  of  the  affection 


INSPISSATED   CERUMEN — CAUSES.  149 

now  under  consideration.  In  another  case,  that  of  a  young 
lady,  suppuration  of  the  drum-head  resulted  from  the  long- 
continued  impaction  of  cerumen.  This  suppuration  was  pre- 
ceded by  very  severe  pain,  from  which  no  relief  was  expe- 
rienced until  the  mass  of  cerumen  was  evacuated  sponta- 
neously, like  a  cork  from  a  bottle  of  champagne,  and,  as  the 
patient  stated,  with  a  report  like  that  of  a  pistol.  The  removal 
of  a  plug  of  cerumen  from  the  auditory  canal  of  the  other 
side,  a  plug  that  was  very  tightly  wedged  in,  saved  the  patient 
from  a  similar  experience  on  that  side. 

Among  the  cases  that  are  appended  to  this  chapter,  will  be 
found  another  where  excruciating  pain  was  one  of  the  promi- 
nent symptoms  of  a  case  of  inspissated  cerumen.  Yet  neither 
pain  nor  vertigo  are  the  ordinary  symptoms  of  this  disease ; 
impairment  of  hearing  and  tinnitus  are  the  usual  ones. 

Causes. — I  do  not  think  the  causes  of  inspissated  cerumen 
are  as  plainly  recognized  as  we  could  wish.  It  was  once  my 
opinion  that  it  was  usually  a  local  affection,  and  while  I  still 
believe  that  there  are  some  cases  where  the  inspissation 
of  the  cerumen  is  the  only  disease  which  affected  many 
ears  that  are  found  filled  with  hardened  wax,  I  am  persuaded 
that  in  the  majority  of  cases,  even  after  we  have  excluded 
such  ones  as  those  in  which  the  cerumen  hardens  upon  the 
remains  of  an  ulcerating  drum-head,  or  in  an  ear  that  has  for 
a  long  time  been  affected  by  chronic  catarrh  of  the  middle  ear,, 
inspissated  cerumen  is  a  symptom  of  an  inflammatory  affec- 
tion of  the  lining  membrane  of  the  canal. 

In  some  cases  it  is  possible  to  believe  that  this  inflamma- 
tory affection  may  have  passed  away  before  the  hardened 
cerumen  is  removed ;  so  that  after  syringing,  the  hearing  dis- 
tance becomes  normal,  and  the  tinnitus  is  relieved.  What 
this  process  is,  I  cannot  say ;  but  I  look  with,  suspicion  upon 
any  ear  in  which  the  cerumen  hardens  and  becomes  fre- 
quently impacted. 

I  have  seen  several  cases  in  which  impaction  of  the  ceru- 
men has  occurred  more  than  a  dozen  times  in  a  few  years,  and 
I  have  found  that  some  of  these  persons  were  beginning  to 
suffer  from  disease  of  the  middle  ear.     I  have  been  unable  to 


150  INSPISSATED   CERUMEN — CAUSES. 

see  that  increased  activity  of  the  other  sudoriparous  or  sweat 
glands  of  the  body,  or,  in  other  words,  excessive  perspiration, 
was  at  all  a  necessary  accompaniment  of  these  cases.  Some- 
times the  patients  with  inspissated  cerumen  say  that  they 
perspire  excessively  ;  and  again,  they  are  not  at  all  aware  of 
any  such  peculiarity.  Often,  indeed,  they  state  positively  that 
they  do  not  perspire  any  more  than  is  natural.  I  think,  there- 
fore, we  must  reject  this  from  among  the  causes  of  this  disease. 

I  have  no  doubt  but  that  the  bad  habit  of  cleansing  the 
auditory  canal  with  the  end  of  a  towel,  or  with  an  aurilave — 
a  bit  of  sponge  fastened  on  a  handle — or  the  like,  has  a  ten- 
dency to  pack  the  cerumen  in  the  canal ;  but  after  all,  a  cause 
must,  I  think,  be  sought  for  behind  this,  and  this  is  possibly 
to  be  found  in  an  inflammation  of  the  middle  ear,  which  has 
extended  to  the  auditory  canal,  or  in  an  inflammation  of  the 
canal  itself. 

I  have  observed  that  almost  all  patients  suffering  from 
inspissated  cerumen  ascribe  the  attack  to  "  cold  "  which  they 
have  taken.  In  many  of  these  cases  no  evidence  is  found  to 
substantiate  the  theory,  for,  as  all  my  readers  know,  patients 
are  very  apt  to  ascribe  all  kinds  of  diseases  to  cold,  even  when 
they  cannot  positively  remember  that  they  have  suffered  from 
a  cold  in  the  head,  throat,  or  chest. 

Yet  many  cases  have  come  to  me,  in  which  there  was  a 
nasopharyngeal  catarrh  co-incident  with  the  impaction  of 
cerumen,  or  with  the  aural  symptoms. 

I  suppose  a  very  slight  swelling  of  the  auditory  canal 
would  prevent  the  free  removal  of  the  cerumen,  which  natu- 
rally takes  place  from  the  motion  of  the  lower  jaw,  as  it  presses 
upon  the  lower  part  of  the  wall  of  the  meatus.  When  the  wax 
has  once  collected,  partial  evaporation  of  its  watery  contents 
occurs,  and  we  get  the  characteristic  black  color,  and  the  mass 
becomes,  on  its  surface  at  least,  as  hard  as  soft  wood,  and  in 
rare  cases  as  hard  as  some  kinds  of  stone. 

Cases  enough  have  been  seen  to  show,  that  inflammation 
of  the  canal  does  favor  inspissation  of  the  cerumen ;  the  only 
question  upon  which  any  doubt  may  be  thrown  is,  whether 
impaction  of  cerumen  does  ever  occur  without  an  antecedent 
inflammation,   and  from  purely  mechanical  causes,  such  ac 


INSPISSATED   CERUMEN.  151 

packing  of  the  secretion  by  improper  attempts  to  cleanse  the 
canal,  or  from  a  peculiar  tendency  to  excessive  action  of  these 
numerous  glands. 

Certain  it  is,  that  many  cases  require  only  local  treatment, 
and  that  whatever  inflammation  preceded  the  evaporation  of 
the  fluid  of  the  cerumen,  was  fully  removed  when  the  patients 
came  under  treatment. 

Many  patients  suffering  from  chronic  non-suppurative  in- 
flammation complain  that  their  ears  secrete  no  wax.  This 
state  of  things  is  due  to  two  facts : 

One  is,  that  such  patients  are  very  apt  to  syringe  their  ears 
very  frequently,  and  thus  remove  all  the  cerumen  as  fast  as  it 
forms.  The  other  is,  that  the  chronic  catarrhal,  or  proliferat- 
ing process,  probably  extends  to  the  auditory  canal,  and  inter- 
feres with  the  functions  of  the  ceruminous  glands. 

Under  the  guidance  of  Mr.  T.  Wakely,  who  published  an 
account  of  the  wonderful  virtues  of  glycerine  in  the  London 
Lancet,*  the  profession  were  at  one  time  very  much  in  the 
habit  of  recommending  the  use  of  this  agent  to  re-establish 
the  secretion  of  cerumen.  Mr.  Wakeley  even  published  a 
wTork  entitled  "  Clinical  Reports  on  the  Use  of  Glycerine  in 
the  Treatment  of  certain  Forms  of  Deafness."  Mr.  Wilde 
showed  that  the  reporter  of  these  cases  was  not  "  conversant 
with  either  the  normal  or  pathological  appearances  of  the  ear," 
and  glycerine,  after  a  fair  trial,  which  is  still  kept  up  by  some 
physicians,  proved  to  be  of  no  avail  in  relieving  impairment  of 
hearing. 

Its  use  for  the  restoration  of  the  secretion  of  cerumen  was 
about  as  rational  as  the  other  instillations,  of  which  an  account 
has  been  given  in  the  introductory  chapter.  Yet  in  our  own 
century,  a  surgeon  to  a  London  hospital  gravely  recommended, 
as  a  portion  of  a  new  cure  for  deafness,  "  the  finest  curled  wool 
on  the  sheep's  head,  carefully  cut  with  scissors,  and  washed 
in  hot  water,"  and  added  "  that  the  best  wool  is  that  procured 
from  a  small  German  sheep  ;"t  while  in  the  same  city,  Wakely's 
book  was  gravely  noticed  as  a  contribution  to  clinical  medi- 
cine. 

*  Wilde's  Aural  Surgery,  p.  38. 
f  Wilde,  1.  p.,  p.  43. 


152  INSPISSATED   CEEUMEN — TREATMENT. 

Treatment. — The  treatment  of  inspissated  cerumen  is  ex- 
ceedingly simple.  The  hardened  material  should  be  removed  by 
the  use  of  the  syringe  and  warm  water.  The  syringing  should  be 
performed  in  the  manner  that  has  been  depicted  on  page  128. 

In  the  majority  of  cases  but  a  few  minutes  are  necessary 
to  remove  the  mass.  In  some  cases,  however,  we  are  com- 
pelled to  use  a  solvent  for  a  few  hours  prior  to  the  syringing 
process.  I  usually  use  a  saturated  solution  of  the  bicarbon- 
ate of  soda  for  this  purpose. 

The  cerumen  is  sometimes  so  hard,  and  so  tightly  wedged 
into  the  auditory  canal,  that  a  daily  sitting  for  a  week  is  neces- 
sary to  its  removal.  I  have  notes  of  two  such  cases.  In  one 
of  them  I  finally  softened  the  mass  by  the  use  of  fuming  nitric 
acid,  after  having  completely  failed  to  make  any  impression 
upon  it  by  alkaline  solutions  or  oils. 

Professor  S.  D.  Gross  recommends  a  pick  and  curette  for 
the  removal  of  inspissated  cerumen.  He  says,  "  Ear-wax, 
however  hard,  or  however  firmly  impacted,  is  more  readily 
removed  with  such  an  instrument  than  with  any  other  contri- 
vance of  which  I  have  any  knowledge."  *  I  am  constrained 
to  say,  that  I  consider  such  advice  from  so  eminent  a  source 
as  the  distinguished  Professor  in  the  Jefferson  Medical  Col- 
lege, calculated  to  give  a  dangerous  and  false  impression  as 
to  the  proper  method  of  removing  ear-wax.  The  syringe  and 
warm  water  will  be  found  to  be  the  only  means  that  are  neces- 
sary in  ninety-nine  cases  out  of  a  hundred.  The  use  of  the 
"  pick  and  curette,"  or  of  any  pointed  instrument,  is  a  danger- 
ous means  of  removing  inspissated  cerumen,  except  in  the 
hands  of  men  of  very  large  surgical  experience,  who  have 
learned  to  treat  ears  as  if  they  were  soap-bubbles.  It  is  only 
in  the  rare  cases  in  which  the  syringe  fails  that  the  use  of  an 
instrument,  employed  under  a  good  illumination  by  means  of 
the  mirror  and  forehead  band,  should  be  resorted  to.  In  such 
cases  I  have  found  a  Bowman's  probe  a  very  good  means  of 
breaking  up  the  hard  surface  of  the  mass,  after  which  the 
syringe  will  easily  finish  the  work.  I  am  indebted  to  Dr. 
Isaac  Hay,  of  Philadelphia,  for  this  suggestion  of  the  use  of 
the  probe  in  lifting  up  the  hard  cover  of  the  mass. 

*  American  Journal  of  the  Medical  Sciences,  October,  1864. 


INSPISSATED   CEEUMEN.  153 

The  auditory  canal  may  contain  a  surprisingly  large  quan- 
tity of  hardened  cerumen,  and  it  is  necessary  to  examine  the 
ear  quite  often  during  the  syringing  process,  in  order  to  see< 
how  much  remains,  lest  we  continue  the  injections  after  the 
wax  is  removed,  and  thus  injure  the  drum-head.  All  the  wax 
should  be  removed.  The  thinnest  scale  or  flake  left  upon  the 
drum-head,  is  sometimes  sufficient  to  keep  up  the  disturbing 
symptoms.  I  have  seen  two  cases  where  the  diagnosis  was 
correctly  made,  and  the  syringing  undertaken,  and  yet  the 
symptoms  were  not  relieved,  because  a  small  flake  of  wax  was 
left  upon  the  drum-head. 

The  membrana  tympani  is  usually  found  very  much  red- 
dened after  the  removal  of  the  wax  ;  but  this  is  probably  due 
to  the  injections  of  warm  water.  It  is  also  sometimes  pressed 
inward.  This  may  be  due  to  the  mechanical  pressure  which 
has  been  exerted  upon  it  by  the  cerumen,  or  to  the  catarrh  of 
the  tympanic  cavity  which  so  often  accompanies  this  disease. 

If  the  hearing  is  very  much  improved  after  the  removal  of 
the  wax,  the  ear  should  be  protected  from  the  shock  of  sounds 
by  a  little  pledget  of  cotton  placed  lightly  in  the  meatus.  If 
the  drum-head  be  sunken  inward,  Politzer's  method  of  inflat- 
ing the  middle  ear,  or  the  Eustachian  catheter,  should  be 
employed  to  restore  it  to  a  normal  position. 

Since  some  persons  are  disposed  to  frequent  attacks  of 
inspissated  cerumen,  it  is  well  to  advise  them  to  have  the  ear 
syringed  with  warm  water  once  in  two  or  three  months.  It  is 
probable  that  it  requires  a  longer  time  than  this,  for  cerumen 
to  become  so  hard  or  so  tightly  packed  in  the  canal,  that  it 
cannot  be  readily  removed  by  the  patient  or  a  non-medical 
friend. 

It  is  always  well  to  examine  both  ears,  even  when  only  one 
is  complained  of.  I  have  often  found  the  ear  in  which  the 
hearing  was  still  unimpaired,  quite  as  full  of  wax  as  the  other, 
although  it  had  not  yet  become  pressed  upon  the  drum-head, 
and  thus  had  given  no  trouble. 

I  append  a  few  cases,  which  illustrate  what  has  been  said, 
and  which  will,  perhaps,  contribute  to  a  knowledge  of  the  eti- 
ology of  the  disease. 

The  first  was  one  of  the  last  upon  my  case-book  when  this 


154  INSPISSATED   CEKUMEN — CASES. 

chapter  was  finished,  but  it  happens  to  be  of  interest,  inas- 
much as  sudden  and  acute  pain  was  one  of  the  symptoms. 

It  is  inserted,  however,  not  for  its  peculiarity,  but  as  an 
illustration  of  the  ordinary  type  of  these  cases. 

Case  I. — March  5,  1873,  Mr.  De.  S.,  set.  28,  consulted  me  about  a  pain  in 
Lis  ear.  Two  days  since  he  experienced  a  "  buzzing  noise"  in  the  ear,  and  last 
night  he  had  severe  pain  in  it,  which  was  relieved  by  some  liquid  application. 
The  buzzing  noise  still  continues,  and  he  cannot  hear  well  from  the  left  side. 

The  hearing  distance  is— Right  ear  normal ;  Left  ear,  -^L,  or  the  watch  is 
heard  when  pressed  upon  the  auricle. 

Tuning-fork  is  heard  much  better  on  the  left  side. 

Diagnosis — Inspissated  cerumen  in  left  ear. 

The  mass  was  removed  by  syringing,  and  the  hearing  distance  became  f  f 
in  a  few  moments. 

Case  II. — A.  B.,  coachman,  at  N.  T.  Eye  and  Ear  Infirmary,  in  1864.  The 
patient  complained  of  head  symptoms  for  some  months.  He  ascribes  them  to 
a  sunstroke.  On  cross-examination  it  was  found  that  he  had  never  actually 
suffered  from  sunstroke ;  but  that  since  his  head  symptoms — chiefly  buzzing 
in  the  ear  and  deafness — had  begun,  he  imagined  that  they  were  caused  by  a 
fancied  sunstroke. 

He  stated  that  he  had  been  treated  in  a  New  York  hospital  for  some  weeks, 
but  without  benefit.  His  ears  had  never  been  examined,  and  he  had  concluded 
to  have  their  condition  investigated,  as  many  of  the  symptoms  which  made 
him  "  bad  in  the  head"  were  referred  to  his  ears. 

An  examination  showed  inspissated  cerumen  in  both  ears.  I  have  mislaid 
the  record  which  gave  an  account  of  his  hearing  power ;  but  all  the  trouble- 
some symptoms  were  at  once  relieved  by  the  removal  of  the  mass,  which  was 
done  by  the  use  of  the  syringe.  • 

This  case  is  almost  as  striking  as  that  related  by  Von  Troltsch,  in  which  a 
poor  fellow  was  blistered  and  cupped  to  the  verge  of  severe  depression,  for 
a  supposed  concussion  of  the  brain,  which  proved  to  be  a  case  of  inspissated 
cerumen. 

Case  III. — The  following  case  shows,  I  think,  that  a  swelling  of  the  canal 
may  prevent  the  normal  exit  of  the  cerumen,  and  thus  favor  its  impaction  : 

Miss  Johnson,  sst.  29,  consulted  me,  March  23,  1873,  on  account  of  her  ears, 
and  gave  the  following  history :  For  fourteen  or  fifteen  years  she  had  suffered 
at  intervals  from  abscesses  in  both  ears.  The  hearing  has  been  seriously  im- 
paired on  the  right  side  from  an  ulcer  resulting  from  scarlet  fever,  since  she 
was  five  years  old.  For  the  past  two  or  three  months  the  hearing  has  been 
impaired  in  the  left  ear,  and  she  has  suffered  from  abscesses  near  the  external 
meatus,  which  have  caused  great  swelling  and  tenderness  of  the  parts.  The 
impairment  of  hearing  was  most  marked  in  the  morning.  For  the  last  four 
weeks  she  has  been  constantly  deaf,  although  for  a  few  moments  a  few  days 
ago  she  heard  very  well ;  she  then  felt  as  if  something  had  broken  in  the  ear. 


INSPISSATED   CEEUMEN — CASES.  155 

Hearing  distance,  tested  by  the  watch — Right  ear,  -& ;  L.,  -/,-. 

Diagnosis. — Right  ear,  chronic  suppuration  in  tympanic  cavity.  Left  ear, 
inspissated  cerumen.  A  small  furuncle  was  found  in  the  outer  part  of  the 
canal,  which  was  a  very  narrow  one. 

The  mass  of  cerumen  was  removed  in  about  20  minutes  by  syringing, 
when  the  hearing  distance  became  -45,j-. 

Politzer's  method  of  inflating  the  ear  was  then  employed. 

March  6,  H.  D.  if. 

After  the  use  of  Politzer's  method,  the  hearing  distance  became  f#. 

The  above  case  illustrates  the  theory  of  the  preceding  chapter,  that  inspis- 
sated cerumen  is  in  reality  but  one  of  the  symptoms  of  certain  forms  of 
inflammatory  affection.  In  this  case  the  inflammation  had  not  fully  run  its 
course,  for  the  canal  was  red  and  swelled.  Perhaps,  indeed,  this  was  an 
habitual  condition  of  the  part. 

The  following  case,  which  may  be  considered  a  remark- 
able one,  illustrates  not  only  the  etiology  of  inspissated  ceru- 
men, but  also  the  effect  of  quinine  upon  the  ear  ;  and  I  insert 
it  as  much  to  show  the  influence  of  this  agent  upon  the  audi- 
tory apparatus,  as  for  its  bearing  upon  the  subject  now  under 
discussion. 

It  has  already  been  published,*  but  I  think  it  worthy  a 
wider  circulation  than  it  has  hitherto  obtained. 

Case  IV.— On  the  3d  of  May,  1870,  I  was  consulted  by  Dr.  N.,  set.  34,  on 
account  of  his  throat  and  ears.  He  stated  that  he  had  had  acute  pharyngeal  and 
laryngeal  disease  some  ten  years  before.  He  also  informed  me  that  neither  he 
nor  his  parents  have  any  recollection  of  any  serious  difficulty  with  his  ears  prior 
to  the  date  of  the  attack,  from  whose  consequences  he  is  now  suffering.  The 
laryngeal  inflammation  was  followed  by  chronic  naso-pharyngeal  catarrh,  and 
in  1863  he  was  obliged  to  take  five-grain  doses  of  quinine  for  some  weeks  on 
account  of  nervous  prostration  from  malarial  fever  contracted  in  the  Southern 
States.  These  doses  were  increased  to  ten  grains,  and  cinchonism  was  pro- 
duced. The  symptoms  of  cinchonism  were,  ringing  in  the  ears  and  dizziness. 
In  1864,  the  doctor  again  took  quinine  uutil  the  constitutional  effects  were 
produced,  the  dose  finally  reached  being  twenty  to  twenty-five  grains,  which 
was  taken  every  other  day.  While  employing  the  quinine  in  this  manner  a 
severe  attack  of  otitis  occurred.  The  patient  states  in  a  written  history  taken 
from  his  diary  that  he  recovered  from  the  otitis  under  antiphlogistic  treatment. 

After  recovery  from  the  aural  disease,  Dr.  N.  was  obliged  to  resort  to  the 
use  of  the  qrdnine  on  account  of  the  constitutional  disease, — a  severe  malarial 
neuralgia.  He  took  one  dose  of  fifteen  grains,  which  was  followed  by  pain  in 
the  ears.  Several  efforts  were  made  to  return  to  the  use  of  the  quinine,  but 
pain  in  the  ear  supervened  on  each  dose.     "  From  this  period,  February,  1865," 

*  Transactions  of  the  American  Otological  Society,  1873. 


156  INSPISSATED   CERUMEN — CASES. 

to  quote  the  exact  words  of  the  patient,  "  my  ears  began  to  give  me  constant 
trouble.  I  was  incessantly  annoyed  by  unnatural  noises,  which  would  fre- 
quently reach  such  a  pitch,  for  a  few  moments,  as  to  exclude  all  other  sounds." 
The  naso-pharyngeal  disease  also  increased,  and  in  March,  1865,  he  was  seen, 
on  account  of  the  state  of  his  ears,  by  a  distinguished  practitioner.  The  throat 
was  considered  the  origin  of  the  aural  affection,  and  it  was  accordingly  treated, 
and  was  improved  ;  but  the  ears  remained  in  the  same  condition,  that  is,  they 
were  sensitive  and  affected  by  tinnitus,  and  there  was  some  impairment  of 
hearing. 

After  the  pharynx  had  been  treated,  until  July  of  this  year  (1865),  and  while 
undergoing  treatment,  another  attack  of  otitis  media  occurred,  which  was  pre- 
ceded by  five  weeks  of  facial  neuralgia.  The  use  of  quinine  for  the  relief  of 
these  attacks  had  been  avoided  ;  but  at  last,  the  patient,  worn  out  by  pain, 
took  a  fifteen-grain  dose  of  the  sulphate,  upon  which  the  ear  disease  imme- 
diately supervened.  The  quinine  was  taken  on  July  30th,  and  the  attack  of 
otitis  media  occurred  on  the  next  day.  The  otitis  was  of  so  severe  a  character 
as  to  place  the  doctor  in  a  very  depressed  condition,  and  when  he  recovered 
from  this  and  the  neuralgia,  which  he  did  simultaneously,  to  use  the  patient's 
own  language,  he  was  "  a  perfect  wreck." 

He  then  sailed  for  Europe,  and  in  the  Scotch  Highlands  recovered  from  the 
malarial  disease,  never  having  suffered  from  it  since  up  to  the  present  time. 
The  ears,  however,  became  very  sensitive  to  the  air,  and  cotton  plugs  were 
resorted  to,  and  Dr.  N.  has  never  from  this  time  been  able  to  leave  the  meatus 
open,  even  while  in-doors,  until  the  past  week.  The  hearing  power  was  also 
greatly  impaired  while  in  Scotland ;  the  patient  therefore  went  to  the  south 
of  France,  where  his  ears  were  still  troublesome.  The  aural  symptoms  were 
tinnitus,  a  sense  of  pressure  in  the  auditory  canal,  and  frequent  attacks  of  neu- 
ralgia of  the  fifth  pair.  The  intellect  also  became  somewhat  obscured.  After 
a  year's  stay  abroad,  Dr.  N.  returned  home,  when  the  naso-pharyngeal  catarrh 
returned.  He  then,  under  the  advice  of  a  physician,  began  the  use  of  the 
nasal  douche  for  its  relief,  taking  all  the  precautions  that  are  enjoined,  using 
a  warm  solution  of  common  salt  in  water.  It  was  observed,  however,  that  in 
an  hour  or  two  after  using  the  douche,  there  was  an  uncomfortable  sensation  in 
the  ears  which  became  more  prominent  after  each  application.  The  physician 
then  advised  "  less  pressure  "  in  the  use  of  the  douche  ;  but  the  next  applica- 
tion was  followed  by  severe  pain,  and  this  method  of  treatment  was  abandoned. 
The  patient  was  then  suffering  from  what  was  called  an  inflammation  of  the 
auditory  canal ;  all  treatment  was  given  up  until  September  of  this  year,  when 
another  attack  of  otitis  media  and  of  facial  neuralgia  occurred.  The  next  two 
years  were  spent  in  Italy. 

The  general  health  of  the  patient  was  then  excellent,  but  the  hearing  did 
not  improve,  and  the  patient  was  obliged  to  use  the  cotton  plugs.  Returning 
to  America  in  the  spring,  the  naso-pharyngeal  catarrh,  which  had  not  appeared 
while  in  Italy,  returned,  and  in  April,  pain  occurred  in  both  ears,  for  which  he 
was  treated  by  leeches,  diaphoretics,  and  hot  fomentations  ;  after  this  attack 
the  patient  describes  himself  as  totally  deaf,— unable  to  distinguish  the  loud- 
est sounds.  "  There  was  a  feeling  of  spasmodic  constriction,  and  fulness 
invading  the  cavity  of  the  tympanum,  and  a  sensation  of  pressure  upon  the 


INSPISSATED   CERUMEN — CASES.  157 

drum-head."  On  the  third  day  the  patient  became  able  to  hear  what  war) 
said  to  him,  if  the  words  were  spoken  very  loudly  and  with  the  mouth  applied 
close  to  the  ear ;  as  time  passed  he  became  still  more  improved,  so  that  he 
could  hear  conversation  addressed  specially  to  him  at  a  short  distance,  and  a 
watch  usually  heard  at  four  feet,  at  a  distance  of  two  inches  on  each  side,  II.  =  4\-. 

This  was  his  condition  when  he  first  came  under  the  writer's  observation, 
on  May  3,  1870.  I  found  that  the  general  nervous  system  of  Dr.  N.,  from  his 
years  of  suffering,  was  in  a  highly  sensitive  condition.  His  pharynx  was 
highly  congested,  the  uvula  very  long,  and  both  auditory  canals  were  extremely 
sensitive  and  plugged  with  hard  wax.  For  two  weeks  the  patient  was  under 
my  care,  during  which  time  I  cut  off  the  uvula,  and  made  many  attempts  to 
remove  the  impacted  wax  by  syringing,  and  the  use  of  the  forceps  ;  but  in  all 
these  attempts  I  failed,  in  consequence  of  the  hardness  of  the  cerumen  and  the 
tightness  with  which  it  was  held  by  the  auditory  canal,  and  also  because  the 
ear  was  extremely  tender  to  the  slightest  touch. 

At  the  end  of  this  time,  the  patient  was  suddenly  called  to  Minnesota,  and 
I  did  not  see  him  again  until  June  26,  1872,  when  he  presented  himself  and 
gave  the  following  history  of  the  time  that  had  elapsei.  The  very  small 
quantity  of  wax  removed,  and  the  cutting  off  of  the  uvula,  had  relieved  the 
pharynx  and  ears  to  some  slight  extent,  and,  the  climate  being  adapted  to  his 
condition,  he  did  very  well,  except  that  the  hearing  was  impaired. 

On  June  18,  1871,  another  attack  of  otitis  occurred,  which  caused  some 
considerable  discomfort,  although  it  was  a  less  severe  attack  than  those  which 
had  preceded  it.  The  otitis  again  occurring,  the  patient  came  to  me,  on  the 
date  above  mentioned  ;  more  than  two  years  from  the  first  visit.  I  found  him 
suffering  severe  pain,  for  which  he  was  taking  anodynes  ;  the  ears  were 
about  in  the  same  state  as  when  I  last  saw  him.  The  hearing  distance  was 
about  -4a8-,  the  canals  were  plugged  with  hardened  wax  ;  the  patient  appeared 
in  fair  physical  condition,  but  mentally  he  was  excited  and  slightly  irritable 
and  depressed. 

I  proceeded  to  remove  the  impacted  wax,  and  that  from  the  right  ear  came 
away  on  the  second  day.  It  was  so  tightly  wedged  in  that  the  removal,  which 
was  effected  by  the  syringe  and  forceps,  caused  severe  pain,  although  the  walls 
of  the  canal  were  not  touched.  On  the  fifth  day,  after  the  use  of  various  agents 
to  soften  the  mass  of  cerumen  in  the  left  ear,  I  burned  it  with  nitric  acid,  and 
then  succeeded  in  removing  it.  This  removal  also  caused  great  pain.  The 
membranse  tympani  were  suppurating,  that  is,  the  outer  layers,  and  they  were 
somewhat  sunken,  especially  along  the  handle  of  the  malleus.  The  use  of  a 
solution,  nitrate  of  silver  40  gr.  ad  1  j,  and  inflation  by  Politzer's  method,  soon 
restored  them  to  a  normal  appearance,  except  that  the  curvature  remained 
altered.  The  sensitiveness  of  the  ears  was  removed,  so  that  they  could  be 
touched,  applications  made  to  the  drum-head,  and  so  on,  without  producing  any 
unpleasant  sensations.  The  hearing  distance  became  -4a8-  on  the  right  side,  and 
was  improved  on  the  left,  but  to  what  extent  I  do  not  know,  not  having  seen  the 
patient  for  some  time.  He  became  able  to  sleep  without  an  anodyne.  The 
cotton  plugs  which  had  been  worn  for  years  were  now  removed,  and  he  became 
altogether  a  different  person,  as  regards  his  mental  condition. 

I  think  we  must  regard  the  otitis  in  this  case,  although  to  a  certain  extent 


158  INSPISSATED   CERUMEN — CASES. 

dependent  upon  the  naso-pharyngeal  catarrh,  as  chiefly  caused  by  the  use  of 
quinine.  By  looking  at  the  history  and  observing  how  promptly  and  invaria- 
bly the  pain  in  the  ears'  occurred  in  several  instances  after  the  use  of  the  agent, 
we  are  forced  to  the  conclusion  that  quinine  was  the  exciting  cause  of  the 
aural  inflammation.  At  what  date  the  impaction  of  wax  occurred,  we  cannot 
positively  determine.  I  am  disposed  to  believe  that  it  was  at  the  time  the 
patient  awoke  profoundly  deaf,  in  April,  1870,  or  more  than  two  years  before 
it  was  removed.  The  wax  was  certainly  there  one  month  after,  in  May,  1870, 
when  I  first  saw  him. 

The  condition  of  the  patient's  mind  is  illustrated  by  the  fact  that  he  should 
allow  two  years  to  pass  away  with  no  attempt  to  remove  a  foreign  body,  from 
whose  partial  removal  he  had  obtained  some  relief,  and  which  he  believed  to 
be  one  of  the  causes  of  his  impaired  hearing.  I  can  only  partially  account  for 
this  delay,  by  supposing  that  my  efforts  at  softening  and  removing  the  mass 
had  so  far  succeeded  as  to  lift  the  cerumen  from  the  drum-head,  and  thus  give 
partial  relief.  Indeed,  the  plug,  which  I  took  out  on  the  second  day,  was  on 
its  way  out,  and  would,  I  think,  have  soon  escaped  spontaneously,  with  one  of 
the  loud  reports  with  which  hardened  wax  sometimes  shoots  from  the  auditory 
canal.  The  structure  of  the  plugs  was  that  usually  found,  that  is,  cerumen  in 
layers ;  but  there  was  some  epidermis  exfoliated,  and  also  some  pus  between 
the  mass  of  wax  and  the  canal. 

The  case  seems  to  me  to  be  one  of  those  which  have  been  reported,  where 
inflammation  of  the  integument  lining  the  canal  was  one  of  the  causes  of 
impaction  of  wax,  and  it  may  be  a  contribution  to  the  etiology  of  that  dis- 
ease. The  earlier  history  also  illustrates  the  effect  of  quinine  upon  the  ear, 
which  I  am  inclined  to  suspect  is  sometimes  an  inflammation  of  the  conduct- 
ing portions,  as  well  as  of  the  acoustic  nerve  or  labyrinth.  We  have  long 
known  of  the  latter  effect,  but  the  former  has  not  been  often  observed. 

The  following  case  occurred  in  my  clinic  at  the  Brooklyn 
Eye  and  Ear  Hospital,  and  was  reported  by  Dr.  David  Web- 
ster,* who  was  then  House  Surgeon. 

It  illustrates  the  serious  inflammatory  trouble  that  may  be 
caused  by  inspissated  cerumen,  a  fact  which  has  been  already 
alluded  to  in  this  chapter. 

Case  V. — "  D.  H.,  aged  28,  laborer,  presented  himself  at  Dr.  Eoosa's  clinic,  at 
this  hospital,  Nov.  1st,  1870.  Five  days  previously  his  right  ear  was  attacked 
with  pain,  tinnitus,  and  deafness,  which  symptoms  had  gradually  increased  up 
to  date.  He  had  slept  but  little  for  the  last  two  nights,  in  consequence  of  the 
severity  of  the  pain.  He  could  hear  the  ticking  of  an  ordinary  watch  at  the 
distance  of  only  one  inch. 

Upon  examination  we  observed  a  little  puffiness  of  mastoid  process,  and  some 
swelling  back  of  the  angle  of  the  lower  jaw  and  of  the  walls  of  the  meatus. 

*  Medical  Record,  vol.  v.,  p.  536. 


INSPISSATED   CERUMEN.  159 

There  was  also  some  pharyngitis.  Through  the  aural  speculum  the  external 
meatus  was  seen  to  be  plugged  with  hard  wax.  This  was  removed  by  care- 
fully syringing  the  ear  with  warm  water.  Some  pus  was  found  in  the  canal, 
and  at  first  the  membrana  tympani  was  thought  to  be  perforated,  but  upon 
more  careful  examination  it  was  found  to  be  intact,  though  a  complete  exam- 
ination of  it  was  rendered  impossible  by  the  narrowing  of  the  meatus  conse- 
quent upon  the  swelling. 

Politzer's  method  for  inflating  the  middle  ear  was  practised,  and  the  patient 
was  directed  to  fill  his  ear  frequently  with  warm  water. 

Nov.  2. — He  said  that  the  pain  was  so  relieved  that  he  rested  well  last  night, 
and  complained  more  of  a  sensation  of  soreness  than  of  pain.  The  tinnitus 
and  swelling  were  undiminished,  but  the  hearing  distance  had  risen  to  ten 
inches.  On  using  Politzer's  method,  the  patient  felt  the  air  enter  neither  ear, 
and  when  this  was  done  again,  with  the  addition  of  the  vapor  of  chloroform, 
the  air  was  felt  only  in  the  left.  He  was  directed  to  continue  the  use  of  warm 
water. 

Nov.  3. — The  swollen  walls  of  the  meatus  had  become  more  sensitive  to  the 
touch,  and  the  pain  had  returned.  He  was  treated  by  means  of  the  warm 
aural  douche,  Politzer's  method  again  used,  and  the  entrance  to  the  meatus 
stuffed  with  cotton  in  order  to  exclude  the  cold  air. 

Nov.  5. — The  swelling  had  increased.  Dr.  Prout,  who  saw  the  patient  for 
Dr.  Roosa,  made  two  incisions  in  the  walls  of  the  meatus— one  backwards,  the 
other  upwards.  Pus  followed  the  knife  in  the  latter.  The  pain  caused  by 
the  incisions  was  immediately  relieved  by  the  warm  douche  (Clarke's  aural 
douche). 

Nov.  8. — He  was  again  seen  by  Dr.  Roosa.  There  was  an  abscess  in  the 
anterior  wall  of  the  meatus,  just  behind  the  tragus.  This  was  opened,  and  a 
considerable  quantity  of  thick  pus  evacuated.  The  meatus  was  as  thoroughly 
as  possible  cleansed  by  syringing,  and  the  use  of  pledgets  of  cotton. 

Nov.  15. — The  swelling  had  so  far  diminished  that  the  drum-head  could  be 
properly  examined.  It  was  covered  with  bits  of  wax  and  epidermis,  which 
were  removed  by  gentle  syringing.  The  hearing  distance  was  twelve  inches. 
A  week  later  Dr.  Roosa  pronounced  the  patient  cured,  so  far  as  the  ear  was 
concerned,  all  signs  of  irritation  having  disappeared,  no  tinnitus  remaining, 
and  the  hearing  function  being  restored  to  its  normal  condition.  A  gargle  of 
alum  and  chlorate  of  potassa  was  used  for  his  pharyngeal  trouble. 

A  point  of  especial  interest  in  this  case  is  its  causation.  As  the  membrana 
tympani  remained  intact  throughout,  and  inasmuch  as,  even  after  the  swell- 
ing had  subsided,  small  particles  of  wax  still  adhered  tenaciously  to  the  surface 
of  the  drum-head  and  of  the  walls  of  the  meatus,  we  could  not  avoid  the  con- 
clusion that  it  was  due  to  the  impacted  cerumen  acting  as  a  foreign  body. 

This  is  the  only  case  of  the  kind  that  has  occurred  in  this  hospital  during 
the  two  and  a  half  years  of  its  existence,  during  which  time  about  eleven  hun- 
dred and  fifty  ear  cases  have  been  treated." 

Dr.  O.  D.  Pomeroy,*  one  of  my  colleagues  at  the  Man- 

*  Transactions  of  the  American  Otological  Society,  1872. 


160  INSPISSATED   CEKUMEN. 

hattan  Eje  and  Ear  Hospital,  lias  tabulated,  from  the 
records  of  that  institution,  200  ears  in  which  the  diagnosis  of 
inspissated  cerumen  was  made.  The  cases  were  found  to  be 
accompanied  or  caused  by  middle  ear  disease  in  a  very  large 
proportion  of  cases,  for  the  hearing  was  found  to  be  normal 
after  removal  of  the  cerumen  in  but  27  ears.  It  must  be 
remembered,  however,  that  the  diagnosis  was  evidently  set 
down  in  this  table,  as  in  Toynbee's  cases,  as  inspissated  ceru- 
men, when  the  predominant  affection — for  example,  disease 
of  the  labyrinth,  chronic  suppuration  in  the  tympanic  cavity, 
and  so  on — should  have  been  given  as  the  true  diagnosis. 

Again,  if  a  patient  got  nearly  perfect  relief  from  the 
removal  of  the  cerumen,  but  the  hearing  distance  was  not  quite 
normal,  the  case  did  not  appear  among  those  with  perfect 
hearing,  while  it  is  possible  that  the  normal  hearing  power 
was  restored  in  a  few  days,  when  the  mechanical  effects  of 
the  packing  of  the  cerumen  had  passed  away. 

Pain  worthy  of  note  was  caused  by  the  cerumen  in  12  ears 
of  the  200. 

COMPOSITION  AND  FUNCTIONS  OP  CEEUMEN. 

According  to  J.  E.  Petrequin*  cerumen  is  of  a  smeary  con- 
sistency, on  account  of  the  soapy  material  made  by  the  potash 
which  it  contains.  A  part  of  it  is  soluble  in  water,  another  in 
water  and  alcohol.  It  also  contains,  according  to  the  same 
authority,  about  one-tenth  per  cent  of  water,  a  mixture  of  oil 
and  stearine,  and  a  dry  material  not  soluble  in  water,  alcohol, 
and  ether,  in  which  chalk,  and  traces  of  chalk  and  soda  are 
found.  As  age  advances,  the  parts  of  the  cerumen  that  are 
soluble  in  water  and  soluble  substances  increase,  but  those 
soluble  in  alcohol  diminish  ;  so  that  in  older  persons  the  ceru- 
men becomes  dry  and  brittle. 

Kessel's  account  of  the  cerumen  has  already  been  given 
on  page  63 ;  but  it  may  be  well  to  repeat  his  statements  at 
this  point. f     The  contents  of  the  ceruminous  glands  only  dif- 

*  Arcliiv  fur  Ohrenheilkunde,  Bd.  V.,  p.  230,  from  Comptes  Rend,  de 
l'Acad.  des  Sciences,  1869,  xvi.,  pp.  940,  9 11. 

f  Strieker's  Manual,  The  External  Ear,  by  Kessel,  translated  by  J.  Orne 
Green,  p.  951. 


INSPISSATED   CEEUMEN.  1G1 

fer  from  those  of  the  sweat  glands  in  the  fact  that  the  former 
contain  masses  of  very  fine  coloring  matter.  The  substance 
secreted  by  the  ceruminous  and  sebaceous  glands  iogether,  is  a 
yellowish-white,  rather  fluid  material,  which  consists  essentially 
of  small  and  large  fat  globules,  corpuscles  of  coloring  matter  in 
masses,  and  cells  in  which  single  globules  of  fat  and  coloring 
matter  are  embedded  ;  hairs,  and  scales  of  epidermis  from  the 
lining  of  the  canal  are  also  found  in  the  canal. 

Those  who  are  curious  in  regard  to  the  opinions  of  the  last 
century  and  the  early  part  of  the  present  one,  on  the  subject 
of  the  functions  of  the  cerumen  and  the  affections  of  the  ear 
caused  by  the  suppression  of  the  secretion,  will  find  the  book 
of  Thomas  Buchanan,*  of  Hull,  interesting  reading. 

Mr.  Buchanan  ascribed  most  of  the  diseases  of  the  ear  to 
impaction  of  cerumen  or  stoppage  of  its  secretion.  He  be- 
lieved that  it  had  a  very  important  function  in  relieving  the 
harshness  of  the  waves  of  sound.  If  it  were  not  for  the  lining 
of  cerumen  which  is  in  the  meatus,  the  waves  of  sound  would 
fall  irregularly  upon  the  drum  membrane  and  cause  it  to 
vibrate  unevenly. 

Mr.  Buchanan  also  explained  Mr.  Everard  Home's  case  of 
double  hearing  by  his  theory  of  deficient  secretion  of  the  ceru- 
men. It  was  that  of  a  music  teacher,  who  found  that  after  a 
cold  the  pitch  of  one  ear  was  half  a  note  deeper  than  the  other, 
and  that  a  simple  tone  was  not  recognized  as  one  by  both  ears. 

This  is  a  specimen  of  the  author's  fanciful  notions  about 
the  important  functions  of  this  lubricating  and  protecting 
secretion. 

He  makes  a  disease — Tubulus  Hirsutus — of  the  growth  of 
hairs  in  the  canal,  saying  that  no  one  with  acute  hearing  has 
hairs  growing  over  the  surface  of  the  membrana  tympani. 

He  also  tells  a  singular  story  of  a  man  who  became  very 
deaf,  in  his  opinion  from  years  of  loud  talking  to  a  deaf  wife. 

*  Physiological  Illustrations  of  the  Organ  of  Hearing,  more  particularly  of 
the  Secretion  of  Cerumen,  and  its  effects  in  rendering  auditory  perception  accu- 
rate and  acute,  with  further  remarks  on  the  treatment  of  diminution  of  hear- 
ing, arising  from  imperfect  secretion,  etc.  Being  a  sequel  to  the  Guide  and  to 
the  Illustrations  of  Acoustic  Surgery.  London,  1828. 
11 


162  INSPISSATED   CERUMEN. 

He  imagined  that  the  continued  screaming  at  last  lessened 
the  sensibility  of  the  portio  mollis* 

The  function  of  the  ceruminous  glands  is  probably  that 
of  the  sudoriparous  glands.  They  keep  the  parts  in  which 
they  secrete  pliable,  and  also  prevent  the  ready  admission  of 
insects.  There  is  no  evidence  that  the  cerumen  has  anything 
to  do  with  the  regulations  of  the  intensity  with  which  the 
waves  of  sound  reach  the  ear. 

Children  are  very  rarely  affected  with  inspissated  cerumen. 
I  have  notes  of  but  three  such  cases.  Yet  when  children  suf- 
fer from  chronic  suppuration  in  the  tympanic  cavity,  it  is 
not  an  uncommon  occurrence  to  find  hardened  wax  on  the 
remains  of  the  membrana  tympani. 

Foreign  bodies,  such  as  raisins,  inserted  to  relieve  pain, 
sometimes  form  a  nucleus  about  which  the  cerumen  hardens. 
Dr.  Agnew,  of  this  city,  related  such  a  case  at  one  of  the  meet- 
ings of  the  New  York  Ophthalmological  Society,  where  a  mass 
of  cerumen  was  removed,  in  which  a  raisin  was  found,  which 
the  patient,  a  person  in  middle  life,  remembered  to  have  been 
inserted  some  thirty  years  before.  I  have  removed  masses 
of  wax  in  several  instances,  in  which  insects  were  found  em- 
bedded. 

Mental  hallucinations  have  been  in  rare  instances  relieved 
by  the  removal  of  inspissated  cerumen.  Prof.  Mayer,  form- 
erly director  of  the  Insane  Asylum  at  Hamburg,  is  the  author- 
ity for  this  statement.f 

I  once  saw  a  lady  who,  though  not  regarded  as  a  person 
of  unsound  mind,  seemed  to  be  such,  and  who  complained 
greatly  of  tinnitus  aiirium  in  all  its  varieties.  I  found  the 
ears  full  of  impacted  cerumen  ;  but  she  utterly  refused  to 
allow  me  to  remove  it,  and  I  never  saw  her  but  once.  It 
would  have  been  very  interesting  to  know  the  effect  of  the 
relief  of  the  tinnitus  upon  the  mental  hallucinations  of  which 
she  seemed  to  be  a  victim. 

*  A  good  synopsis  of  Buchanan's  book  will  be  found  in  Lincbe's  Sammlung 
anserlesener  Abhandlungen  und  Beobachtungen  aus  dem  Gebiete  der  Ohren- 
heilkunde,  Bd.  III.     Leipzig,  1836. 

\  Von  Trdltsck  on  the  Ear,  2d  edition,  p.  531. 


CHAPTER    VIII. 

FOREIGN    BODIES    IN    THE    EAR. 

The  usual  point  of  entrance  of  foreign  bodies  into  the  ear 
is  through  the  external  auditory  canal,  although  they  very 
often  pass  beyond  this  part  and  become  lodged  in  the  cavity 
of  the  tympanum,  or  Eustachian  tube,  while  in  some  rare 
instances  a  foreign  body  has  entered  the  ear,  through  the 
Eustachian  tube.  I  have  therefore  entitled  this  chapter, 
Foreign  Bodies  in  the  Ear,  so  that  I  might  properly  include 
all  such  cases  in  the  descriptions  that  are  about  to  be  given. 

The  foreign  bodies  that  are  found  in  the  auditory  canal 
are  very  naturally  placed  under  three  heads :  insects,  or  the 
like  which  creep  into  the  passage ;  their  larvae  which  are  gene- 
rated there,  and  various  articles,  such  as  beads,  buttons,  peas, 
beans,  and  so  on,  which  are  pushed  into  the  ear  by  children 
or  silly  adults. 

INSECTS  IN  THE  EAR. 

When  a  live  insect  gets  into  an  ear,  the  pain  produced  is 
usually  intense  and  agonizing.  Insects  are  more  apt  to  get 
into  the  ears  of  sportsmen  while  hunting  in  thicket  and  under- 
brush, and  of  farmers  laboring  in  the  field,  than  of  dwellers 
in  cities  and  towns.  Yet,  on  the  hot  days  of  summer  when 
insect  life  is  very  active,  the  city  practitioner  will  sometimes 
be  called  to  remove  a  bug  from  the  ear,  if  the  agony  induced 
by  the  foreign  body  do  not  stimulate  some  of  the  family  to  a 
successful  attempt  at  its  removal. 

There  is  an  insect,  which  lives  on  the  leaves  of  fruits  and 
flowers,  and  which,  like  others,  sometimes  flies  into  the  ear, 


164  INSECTS  IN  THE  EAR. 

which  is  called  an  ear-wig,  and  there  was  an  ancient  super- 
stition that  it  crept  into  the  brain  through  the  ear.  The  for- 
fieula  auricularis,  or  so-called  ear-wig,  has  probably  no  more 
propensity  to  fly  into  the  ear,  than  any  other  insect ;  any  of 
the  ordinary  flies  may  do  so. 

The  most  efficient  and  the  speediest  means  of  removing  an 
insect  from  the  ear  is  the  use  of  a  syringe  and  warm  water. 
As  little  animals  usually  get  into  the  ear  when  the  patient  is 
in  the  fields  or  forests,  where  physicians  are  not  always  at 
hand,  laymen  should  be  taught,  in  the  case  of  the  occurrence 
of  such  an  accident,  to  immediately  pour  water  in  the  meatus. 
This  will  disturb  the  animal  and  either  drown  it  or  cause  it 
to  run  out. 

Some  writers  advise  the  use  of  an  oil  dropped  into  the  ear 
before  the  water  is  used,  but  Wilde  and  Von  Troltsch  agree 
that  this  is  an  unnecessary  waste  of  time.  I  have  treated  but 
two  of  such  cases,  and  in  both  of  these  the  insect  was  promptly 
dislodged  by  the  use  of  the  syringe,  and  I  have  no  doubt  that 
the  simple  rilling  of  the  auditory  canal  with  water,  will  cause 
insects  to  come  out  at  once. 

LIVING    LARV^    IN    THE    EAR. 

Insects  sometimes  deposit  their  eggs  upon  the  pus  of  a 
suppurating  ear.  According  to  Wood,  who  is  quoted  by 
Blake,*  insects  have  a  very  acute  sense  of  smell.  "  No  flock 
of  vultures  can  be  directed  more  unerringly  to  their  revolting- 
prey  by  scenting  its  odors  from  afar." 

The  odor  of  an  otitis  media  purulenta  thus  brings  the  insect 
to  deposit  its  eggs  in  the  auditory  canal  and  cavity  of  the 
tympanum,  where  they  soon  become  grubs  or  larvae. 

These  larvse  always  excite  considerable,  and  sometimes  very 
severe  pain,  but  in  the  cases  which  I  have  seen,  the  patients 
complain  much  more  of  the  wriggling  movements  of  the  grubs 
in  the  ear,  than  of  the  pain. 

The  ancient  works  on  aural  diseases  speak  very  much  of 
worms  in  the  ear  and  of  the  proper  means  of  removing  them. 

*  Living  Larvae  in  the  Human  Ear.  Archives  of  Ophthalmology  and 
Otology,  Vol.  II.;  No.  2. 


LIVING  LARViE  IN  THE  EAR.  165 

It  is  probable  that  these  so-called  worms  were  the  larvae  of 
insects  which  germinated  from  eggs  deposited  in  the  pus  of  a 
chronic  suppurative  process.  Certain  it  is,  that  since  the 
habit  of  cleansing  an  ear  from  pus  has  become  a  well-recog- 
nized duty,  the  practitioner  of  the  present  time  sees  very  little 
of  worms  in  the  ears. 

The  pain  from  the  presence  of  these  grubs,  which  ac- 
tually fasten  themselves,  when  hatched,  into  the  tissue  of 
the  canal,  and  bite  upon  it,  as  it  were,  is  apt  to  occur  sud- 
denly. 

An  Austrian  physician,  Dr.  Scheibenzuber*  reports  a  case 
of  a  peasant  ploughing  in  the  field,  who  was  seized  in  an 
instant,  with  a  severe  pain  in  the  ear,  which  he  ascribed  to 
the  flying  in  of  a  bug,  but  the  surgeon  found  the  ear  full  of 
well  developed  larvae. 

I  have  several  times  observed  dead  insects  in  the  pus  that 
was  washed  out  from  an  external  auditory  canal,  and  it  is 
undoubtedly  true,  as  I  have  already  suggested,  that  we  should, 
equally  with  the  ancients,  have  many  cases  of  riving  larvae  in 
the  ear,  were  it  not  that  suppurating  ears  are  usually  now- 
a-days  regularly  cleansed. 

The  larvse  that  have  thus  far  been  found  in  the  ear  are 
those  of  the  muscida  sarcophaga  [Blake,  Gruber),  and  of  the 
muscida  lu cilia  {Blake). 

Dr.  Blake  t  has  made  a  study  of  the  nature  and  habits  of 
these  grubs,  by  taking  them  from  the  ear  at  a  very  early 
period  of  development ;  as  near  as  could  be  ascertained  within 
twelve  hours  of  the  time  of  their  deposit.  He  placed  a  speci- 
men on  the  bottom  of  a  thin  glass  vessel  and  covered  it  with 
a  piece  of  raw  beef,  soaked  in  warm  water,  in  such  a  manner 
that  by  inverting  the  glass  the  movements  of  the  larvae  could 
be  easily  studied  under  the  microscope. 

Dr.  Blake  found  that  the  apparatus  by  which  the  larva 
attaches  itself,  and  which  pierces  and  tears  the  tissue,  is  made 
up  of  a  strong  but  delicate  framework  of  horny  consistency  and 
of  two  hooks  also  of  a  stout  horny  structure,  articulating  with 
this  frame-work.     The  larva  burrows  its  way  into  the  tissue 

*  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  3. 
f  Archives  of  Ophthalmology  and  Otology,  1.  c. 


166  LIVING  LARViE  IN  THE  EAR. 

on  which  it  feeds  by  repeated  extension  and  contraction  of  the 
hooks,  alternately  piercing  and  tearing. 

These  movements  explain  the  agonizing  pain  which  pa- 
tients experience  when  the  larvae  appear  from  the  eggs. 

These  hooks  are  very  large  in  proportion  to  the  size  of  the 
body  of  the  larvse. 

Dr.  Blake  says  that  the  instincts  of  the  animal  lead  it  to 
bury  itself  beneath  the  surface,  and  to  seek  warmth  and  mois- 
ture and  a  soft,  yielding  tissue  for  its  work.  Hence,  they 
are  always  found  at  the  end  of  the  canal  or  in  the  cavity  of 
the  tympanum. 

As  yet,  they  have  always  been  found  in  connection  with 
suppuration  of  the  middle  ear,  with  its  consequent  perforation 
of  the  membrana  tympani. 

The  examination  of  the  auditory  canal  infested  by  living 
larvae,  shows  small  white  worm-like  animals  moving  rapidly 
about,  very  much  as  a  mass  of  common  earth-worms.  As  I 
write,  I  have  before  me  a  number  of  specimens  of  the  dead 
grubs.  They  are  about  a  half  an  inch  in  length,  and  of  the 
diameter  of  a  large  knitting  needle. 

Treatment. — I  have  found  it  impossible  to  remove  living 
larvse  by  means  of  the  syringe.  The  more  they  are  syringed 
the  more  lively  they  become.  Before  the  syringing  is  at- 
tempted, some  agent  should  be  instilled  into  the  ear  which 
will  kill  them,  when  the  syringe  will  usually  remove  them. 
Sometimes,  however,  even  after  death,  their  hooks  penetrate 
so  deeply  into  the  tissue  that  they  can  only  be  removed  with 
the  forceps.  The  forceps  should  not  be  needlessly  used,  how- 
ever, for  even  with  the  most  careful  manipulation,  and  with 
tractable  patients,  they  often  abraid  the  integument  of  the 
canal,  and  thus  cause  pain.  I  have  used  Labarraque's  solu- 
tion of  chlorinated  soda  to  kill  these  grubs,  but  simply  because 
it  was  at  hand  when  I  saw  the  cases. 

The  larvae  have  also  been  killed  by  forcing  the  vapor  of 
chloroform  into  the  cavity  of  the  tympanum  through  the 
Eustachian  tube.  I  believe,  however,  that  it  will  be  sufficient 
to  force  the  vapor  into  the  external  ear,  or  to  instill  some  such 
fluid  as  I  have  mentioned  into  the  canal. 


FOEEIGN  BODIES  IN  THE  EAE.  107 

It  need  hardly  be  said,  that  the  disease  which  allowed  of 
the  deposition  of  the  eggs,  and  the  hatching  of  the  grubs, 
should  be  treated  after  they  have  been  removed.  Even  those 
who  are  advocates  of  allowiog  a  discharge  from  the  ear  to 
remain  unchecked,  will  hardly  defend  such  a  neglect  when 
the  ear  has  become  a  disgusting  receptacle  in  which  larvse  are 
formed. 

FOREIGN  BODIES  IN  THE  EAR. 

The  foreign  bodies  that  are  placed  in  the  ears  of  children 
by  themselves  or  their  playmates,  have,  from  the  time  of  the 
first  writers  on  otology,  formed  a  fertile  field  for  the  labors  of 
surgeons.  The  importance  of  the  subject  has  been  unduly 
magnified.  From  some  source  or  other,  the  laity  have  got  the 
impression  that  a  foreign  body  in  the  ear,  like  a  wild  beast 
accidentally  let  loose  upon  a  civilized  community,  is  to  be 
hunted  down  at  all  hazards.  The  presence  of  a  foreign  body 
in  the  canal  is,  after  all,  however,  not  a  very  serious  matter. 
Children  do  not  usually  push  them  in  far  enough  to  do  any 
harm.  It  is  the  meddlesome  interference  of  nurses  and  friends, 
and  sometimes  of  unwise  practitioners,  that  forces  them  into 
dangerous  positions.  There  was  a  notion  prevalent  in  Eng- 
land, in  Shakspeare's  times,*  that  poison  poured  into  the  ears 
was  as  dangerous  as  if  taken  into  the  stomach ;  and  from  this, 
in  some  manner  or  other,  has  come  the  idea  that  a  foreign 
body  in  the  ear  becomes  at  once  a  very  dangerous  thing. 

It  would  be  well,  if  this  fear  of  foreign  bodies  in  the  ear, 
were  transferred  to  cases  where  they  have  entered  the  eye- 
ball, where  the  most  serious  results  do  occur  from  the  neglect 
to  promptly  remove  a  foreign  substance.  Unskillful  or  indis- 
creet attempts  to  remove  a  foreign  body  are  often  more  dan- 
gerous than  the  foreign  body  itself.  In  the  case  of  a  foreign 
body  in  the  eye,  it  is  the  loss  of  sight  that  is  threatened,  and 
it  is  usually  the  worst  that  can  happen ;  but  it  is  not  a  very 
rare  experience  that  improper  attempts  to  remove  a  foreign 
body  from  the  ear  have  cost  the  fife  of  the  patient. 

*  Play  of  Hamlet. 


168  FOEEIGN   BODIES  IN  THE  EAE. 

"When,  therefore,  a  child  is  brought  to  the  practitioner,  in 
whose  ear  there  is,  or  there  is  supposed  to  be,  a  foreign  body, 
let  him  first,  by  ocular  examination,  be  sure  that  the  diagno- 
sis is  correct,  and  then  let  him  attempt  to  remove  it  by  a  safe 
means. 

"  First  catch  your  hare,"  is  the  quaint  and  familiar  begin- 
ning of  the  receipt  for  cooking  this  animal ;  and  in  imitation 
of  this  sage  advice,  the  writer,  taught  by  experience  that  the 
diagnosis  of  mothers  and  nurses  is  not  always  to  be  trusted, 
would  urge  upon  his  readers  the  wisdom  of  not  attempting  to 
remove  a  foreign  body  which  he  cannot  see.  There  is  nothing 
more  deceptive  than  the  tactile  examination.  Again  and 
again  have  I  seen  physicians  click  what  they  supposed  to  be 
a  foreign  body,  by  means  of  a  probe,  when  they  were  simply 
striking  the  bony  wall  of  the  canal. 

The  surgeon  should  not  take  the  testimony  of  the  most 
intelligent  nurse  in  the  world,  as  to  the  presence  of  a  foreign 
body  in  the  ear,  unless  he  sees  it  himself.  Such  testimony  is 
only  valuable  to  prove  that  a  foreign  body  was  once  in  the 
ear.  Any  attempt  to  remove  a  foreign  body  that  is  not  seen, 
but  which  is  supposed  to  be  in  the  ear,  will  lead  to  a  danger- 
ous and  mortifying  failure. 

Even  when  it  is  seen,  a  forcible  or  violent  attempt  is  always 
a  dangerous  procedure. 

Voltolini,*  in  writing  on  this  subject,  says,  "  that  even  the 
point  of  a  dagger,  if  allowed  to  quietly  remain  in  the  ear,  will 
not  do  as  much  harm  as  forcible  attempts  to  remove  it." 

The  danger  to  be  apprehended  from  attempts  to  remove  a 
foreign  body  by  the  use  of  force  is,  that  it  will  be  pushed 
downwards  in  the  ear,  and  through  the  membrana  tympani 
into  the  cavity  of  the  tympanum,  and  even  into  the  labyrinth. 
Unfortunately  for  the  fair  fame  of  surgical  science,  such  cases 
are  on  record. 

Treatment. — If  the  physician  see  a  case  in  which  a  foreign 
body  has  really  got  into  the  auditory  canal — a  fact  which  he 
should  determine  by  the  use  of  the  speculum  and  the  otoscope 

*  Monatsschrift  fiir  Oiirenlieilkunde,  Jahrgang  II.,  No.  xi. 


REMOVAL  OF  FOREIGN  BODIES.  1G9 

— before  it  has  been  meddled  with,  he  will  almost  always  be 
able  to  remove  it  by  the  process  of  syringing  the  ear  with 
warm  water.  Cnildren,  however  young,  will  readily  submit  to 
this  operation,  and  it  is  almost  always  successful,  if,  as  I  have 
said,  there  have  been  no  previous  manipulations  with  instru- 
ments. 

Unfortunately,  however,  the  cases  are  not  usually  seen  by 
a  physician  until  the  friends  of  the  little  patient,  having  found 
by  the  child's  own  statement  that  a  bead,  or  a  pea,  or  a  shoe- 
button,  or  the  like,  is  in  the  meatus,  and  having  been  able  to 
see  it,  have  pushed  it  well  in,  in  their  misguided  zeal  to  re- 
move that  which  in  itself,  is  not  dangerous  to  the  ear  or  its 
functions. 

Many  cases  are  on  record  where  foreign  bodies,  which  had 
not  occluded  the  auditory  passage,  have  remained  in  it  for 
years  without  doing  harm.  Thus  Wreclen*  reports  a  case  in 
which  he  removed  a  button  from  the  outer  ear,  which  had  re- 
mained at  the  junction  of  the  osseous  and  cartilaginous  canal 
of  a  boy  of  seventeen,  for  twelve  years,  and  without  doing  any 
harm. 

If,  however,  the  foreign  body  has  become  impacted  by  the 
attempts  to  remove  it,  and  if  serious  inflammatory  symptoms 
have  arisen,  it  is  better  to  wait  until  the  latter  has  subsided 
before  any  further  attempts  at  removal  are  made. 

Then,  if  instruments  are  to  be  used,  the  child  should  be 
placed  under  the  influence  of  ether,  and  by  means  of  a  pair 
of  delicate  forceps,  or  a  probe,  it  should,  if  possible,  be  dis- 
lodged from  its  wedged  position,  and  then  removed  by  the 
syringe.  No  manipulation  of  this  kind  should  be  attempted, 
however,  unless  the  foreign  body  is  well  illuminated,  so  that 
the  surgeon  can  see  exactly  what  he  is  doing  during  the  whole 
of  his  manipulations. 

In  cases  where  injections  made  while  the  patient  is  in  an 
upright  position,  do  not  remove  the  foreign  body,  Voltolini 
has  adopted  the  following  method  with  success  : 

The  child  is  laid  upon  a  table,  so  that  its  head  may  hang 
a  little  over  the  end  of  it.     The  membrana  tympani  then  forms 

*  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  12. 


170  BEMOVAL   OP  FOREIGN  BODIES. 

a  plane  with  the  upper  wall  of  the  auditory  canal,  that  runs 
obliquely  .downward.  The  syringing  is  then  performed  as 
usual.  In  two  cases  Voltolini  has  succeeded  in  removing  the 
foreign  body  by  this  manoeuvre,  when  the  ordinary  method  did 
not  succeed. 

Voltolini  has  also  used  the  galvano-caustic  in  breaking 
up  the  so-called  Johannis  brod  or  carob  bean.  The  bean 
having  become  so  firmly  wedged  into  the  ear  that  it  was  im- 
possible to  move  it  one  way  or  the  other,  he  inserted  the 
needle  "  with  lightning-like  rapidity"  into  the  body,  and  when 
it  cooled,  the  bean  broke  with  a  snap  audible  to  the  patient 
and  to  those  about.  When  sufficiently  broken  up,  it  was 
removed  by  syringing. 

Foreign  bodies,  such  as  peas,  beans,  and  the  like,  are 
harder  to  remove,  after  they  have  been  in  the  ear  for  some 
time,  than  metallic  bodies,  because  they  swell,  and  thus  be- 
come wedged  firmly  in  the  canal,  and  if  they  have  been  pushed 
into  the  cavity  of  the  tympanum  they  excite  still  more  trouble 
and  become  still  more  unmanageable. 

I  have  seen  quite  a  number  of  foreign  bodies  in  the  ear, 
and  I  have  never  but  in  one  case  failed  to  remove  them,  and 
then  I  saw  the  patient  but  once  for  a  few  moments.  The 
syringing  did  not  succeed,  and  I  asked  the  mother  to  bring 
the  patient  to  my  clinic  at  the  Hospital,  where  she  might  be 
placed  under  the  influence  of  an  anaesthetic,  but  she  was  not 
brought. 

In  one  case,  when  the  child  first  came  under  my  observa- 
tion, a  button  was  lodged  in  the  cavity  of  the  tympanum  by 
efforts  to  remove  it.  I  syringed  it  in  vain  on  several  occa- 
sions. I  then  proceeded  carefully  with  instruments,  the  pa- 
tient being  anaesthetized.  This  attempt  also  failed.  I  then 
ordered  the  mother  to  syringe  the  ear  three  times  a  day,  which 
was  necessary  on  account  of  the  purulent  otitis  media  which 
had  been  set  up  by  the  presence  of  the  button  in  the  cavity  of 
the  tympanum,  and  I  also  advised  the  careful  use  of  poul- 
tices. To  my  delight,  in  about  four  weeks  I  had  the  satisfac- 
tion of  removing  the  button  from  the  canal,  where  it  had  been 
brought  by  the  syringing  and  the  use  of  the  poultices. 

I  have  now  under  my  care  a  little  child  of  four  years  of 


BEMOVAL  OP  FOREIGN  BODIES.  171 

age,  who,  according  to  her  own  statement  to  her  nurse,  put  an 
ordinary  shoe-button,  made  of  papier-mache,  in  her  ear.  As  soon 
as  the  nurse's  attention  was  called  to  the  case,  she  reported  it 
to  the  family,  who  sent  for  a  physician,  who  saw  the  button, 
and  attempted  to  remove  it,  under  chloroform,  using  for  this 
purpose  a  small  elevator.  It  is  stated  that  half  the  button  was 
removed  in  this  way  ;  but  the  other  half  could  not  be  dislodged. 

In  a  few  days,  the  child  having  become  very  weak  from  the 
operation  and  the  anaesthetic,  from  the  chloroform,  I  was  called 
in  consultation.  A  careful  examination  was  made.  The  mem- 
brana  tympani  was  found  to  be  gone,  there  was  considerable 
swelling  of  the  canal,  but  the  button  was  not  to  be  seen  either 
by  the  physician  or  myself,  although  he  thought  he  detected 
it  with  the  probe. 

Another  surgeon  was  called  in,  and  he  was  not  able  to  find 
a  foreign  body,  and  the  child  has  been  under  treatment  ever 
since  for  a  chronic  suppuration  of  the  middle  ear,  the  mem- 
brana  tympani  and  the  ossicula  being  gone,  and  the  hearing 
irretrievably  injured. 

I  recite  such  cases  in  order  to  show  what  harmful  conse- 
quences may  result  from  the  most  conscientious  attempts  to 
remove  a  foreign  body  with  instruments. 

No  engravings  are  given  in  this  volume  of  the  numerous 
hooks,  forceps,  perforators,  drills,  picks,  et  id  genus  omne,  that 
have  been  devised  by  surgeons,  with  more  ingenuity  than  wis- 
dom, for  the  removal  of  foreign  bodies  from  the  ear,  because  I 
firmly  believe  that  the  vast  majority  of  such  instruments  are 
very  dangerous  weapons  ;  while  they  are  usually  greatly  infe- 
rior in  efficiency  to  the  use  of  the  warm  water  and  syringe. 
Cases  will  occur,  however,  in  which  syringing  will  not  be  suf- 
ficient ;  but  I  should  not  hasten  unduly,  unless  the  body  had 
become  impacted  in  the  tympanic  cavity,  or  was  causing 
unpleasant  or  serious  symptoms.  In  such  cases  the  ordi- 
nary armamentarium  of  the  surgeon  will  contain  instruments 
adapted  for  the  individual  cases  as  they  occur.  Let  him 
remember,  however,  that  once  beyond  the  membrana  tympani, 
he  is  dealing  with  parts  whose  injury  becomes  dangerous  not 
only  to  hearing  but  to  life. 

The  ancient  suggestion  of  Hippocrates  and  Du  Yerney  (see 


172  REMOVAL  OF  FOREIGN  BODIES. 

page  36),  to  detach  the  auricle  from  the  ear,  will  be  found 
worthy  of  consideration  when  it  is  found  impossible  to  remove 
a  foreign  body  through  the  canal.  It  certainly  cannot  be  a 
dangerous  operation,  and  it  is  much  to  be  preferred  to  any 
risk  of  serious  injury  to  the  cavity  of  the  tympanum  or  the 
labyrinth. 

Dr.  Lowenberg*  reports  an  ingenious  method  by  which  he 
removed  a  small  ivory  ball,  from  the  tip  of  a  quill  penholder, 
which  had  been  forced  into  the  ear  of  a  boy  nine  years  of 
age.  Yarious  attempts  at  removal,  by  other  hands,  wounded 
the  canal,  perforated  the  membrana  tympani,  and  excited 
severe  inflammation.  After  the  inflammation  had  subsided, 
Dr.  Lowenberg  attempted  to  remove  the  body  by  syringing, 
by  Valsalva's  and  Politzer's  methods  of  inflating  the  ears ; 
but  he  failed.  He  then  extracted  the  ball  by  bringing  the 
point  of  a  small  brush,  dipped  in  joiners'  glue,  in  contact 
with  its  outer  surface,  allowing  the  glue  to  harden,  and  then 
extracting  brush  and  ball  together. 

Dr.  E.  H.  Clarke,  who  is  quoted  by  Blake  in  the  same 
report  from  which  I  have  taken  the  description  of  Dr.  Lowen- 
berg's  method,  once  adopted  a  similar  procedure  with  success. 
The  foreign  body  was  a  hard,  smooth  ball,  and  it  was  ex- 
tracted by  passing  a  thread  through  a  small  square  of  adhe- 
sive plaster,  and  bringing  the  latter,  by  means  of  a  fine  tube, 
into  contact  with  the  surface  of  the  ball,  when  sunlight  was 
concentrated  upon  it  by  means  of  a  lens,  until  it  softened  and 
adhered,  when  it  was  easily  extracted. 

These  two  methods  are  certainly  to  be  commended  as  both 
ingenious  and  safe. 

It  is  possible  that  the  reader  is  ready  to  believe,  that  I  am 
attaching  too  much  importance  to  this  subject  of  the  removal 
of  foreign  bodies  from  the  ear :  but  I  am  sure  that  any  one 
who  has  taken  the  pains  to  look  over  the  literature  of  this 
subject,  or  who  has  seen  many  cases,  will  feel  that  too  much 
stress  cannot  well  be  laid  upon  the  necessity  for  skill  and  wis- 
dom in  the  management  of  these  cases. 

I  will,  however,  close  the  chapter  by  some  statistics  which 

*  Report  on  the  Progress  of  Otology,  by  C.  J.  Blake,  Transactions  Ameri- 
can Otological  Society,  1872. 


FOEEIGN  BODIES  IN  THE  EUSTACHIAN   TUBE.  173 

have  been  carefully  prepared  by  Dr.  Mayer,  of  Munich,  which 
illustrate  this  subject,  and  with  the  insertion  of  a  painful  case, 
from  Mr.  Pilcher's  book  on  the  ear,  which  is  one  I  have  been  in 
the  habit  of  repeating  to  my  class,  as  a  warning  to  those  who 
try  to  extract  from  an  ear  what  they  have  never  seen. 

My  distinguished  countryman,  Dr.  J.  Marion  Sims,  of  this  city,  published 
an  article,  illustrated  by  three  cases,  in  the  American  Journal  for  Medical  Sci- 
ences, vol.  ix.,  1845,  that  very  warmly  and  ably  advocated  the  use  of  the 
syringe  for  the  removal  of  foreign  bodies  from  the  ear,  but  which  did  not 
receive  the  attention  it  deserved. 


FOEEIGN  BODIES  IN  THE  EUSTACHIAN   TUBE. 

Among  the  cases  whose  statistics  will  be  given  as  reported  by  Dr.  Mayer, 
two  will  be  noticed  where  laminaria  bougies  were  broken  off  in  the  Eustachian 
tube.  Dr.  Hecksher,*  of  Hamburg,  relates  an  interesting  case  that  belongs  to 
this  class.  The  patient  was  a  principal  of  a  college,  who  had  been  accus- 
tomed to  treat  his  own  ears — which  were  affected  with  chronic  catarrh — by  the 
use  of  the  Eustachian  catheter. 

Dr.  Hecksher  received  a  telegram  one  day  from  the  patient,  for  whom  he 
had  occasionally  prescribed,  stating  that  he  had  got  a  foreign  body  in  one  of 
his  Eustachian  tubes.  When  Dr.  Hecksher  reached  the  patient,  he  gave  the 
following  history  : 

He  had  introduced  through  a  metallic  catheter  a  whalebone  probe  into  the 
tube.  On  the  end  of  this  probe  was  fastened  with  a  silk  thread  a  raven's 
feather,  which  he  used  for  the  purpose  of  washing  away  mucus  from  the  tube. 

One  evening  as  he  was  using  the  apparatus,  he  drew  back  the  probe  with- 
out the  feather,  and  he  found  that  he  had  left  it  in  the  tube.  It  caused  so 
much  pain  that  he  could  not  sleep.  Attempts  were  made  by  a  physician  to 
remove  the  foreign  body,  but  they  failed.  Dr.  Hecksher  then  attempted  to 
remove  the  body,  but  the  parts  were  so  swollen  that  he  could  not  practice 
rhinoscopy,  and  see  the  feather,  and  he  failed  with  various  kinds  of  forceps  to 
remove  it. 

So  much  inflammation  ensued  that  he  was  obliged  to  desist,  and  use  anti- 
phlogistic treatment ;  but  the  patient  finally  removed  the  feather  himself  by 
the  aid  of  the  catheter  introduced  in  the  usual  way,  and  his  finger  passed 
behind  the  uvula. 

CASES. 

Dr.  Ludwig  Mayer  \  has  collected  the  cases  of  foreign 
bodies  in  the  ear  that  he  has  been  able  to  find  in  the  litera- 

*  Monatsschrift  fur  Ohrenheilkunde,  1870,  No.  1. 

\  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  IV,  No.  1. 


171  STATISTICS   OP  FOREIGN  BODIES  IN  THE  EAR. 

ture  of  the  fifty  years  preceding  1870.     The  whole  number  is 
77.     Of  these  persons 

16  were  between  1  and  10  years  of  age. 
10     "  "       10    "     20     " 

10     "  "       20    "     50     " 

1  was  over        50  "  " 

The  age  of  the  remainder  is  unstated. 

In  66  cases  the  foreign  body  was  in  the  auditory  canal, 
8  were  in  the  cavity  of  the  tympanum,  and  3  in  the  Eustachian 
tube.  Of  the  three  cases  in  the  Eustachian  tube,  two  were  at 
the  pharyngeal  orifice.  In  the  third  case,  a  barley-corn  pro- 
jected from  the  pharyngeal  orifice,  and  at  the  post-mortem 
section — it  is  not  stated  of  what  disease  the  patient  died — the 
foreign  body  was  found  to  reach  into  the  osseous  tube. 

In  two  of  the  cases  the  foreign  body  was  in  the  ear  but 
twelve  hours  before  seen  by  the  surgeon  who  reported  them.  In 
only  12  of  the  cases  was  the  foreign  body  in  but  a  short  time, 
varying  from  days  to  weeks.  In  the  remainder,  they  were  in 
for  years.  Four  were  in  for  four  years,  two  for  twenty  years, 
one  for  forty-five,  and  one  for  more  than  sixty  years. 

The  substances  found  were — a  needle,  carob  beans  (6), 
beans  (3),  cherry  pits  (6),  living  larvse  (4),  peas  (1),  a  wisdom 
tooth  of  the  upper  jaw,  a  grain  of  coffee,  a  snail,  pearls  (2), 
point  of  a  glass  syringe,  a  glass  ball,  wads  of  cotton  (6),  a 
carious  tooth,  a  piece  of  hard  coal,  a  wad  of  paper,  a  gun  cap, 
a  piece  of  bone,  a  piece  of  bread,  a  bit  of  lead,  laminaria 
bougies  in  the  tube  (2),  a  millet  seed,  a  piece  of  coral,  a 
barley-corn  in  the  tube,  and  an  agate  stone. 

Dr.  Mayer  finds,  on  an  analysis  of  these  cases,  that  the 
attempts  to  remove  the  foreign  bodies  had  usually  caused 
much  more  trouble  in  the  ear  than  their  presence. 

In  48  of  the  77  cases,  functional  and  pathological  changes 
are  said  to  have  occured  as  a  result  of  the  presence  of  the 
foreign  bodies.  In  11  of  the  cases  it  is  reported,  that  the 
attempt  at  removal  caused  these  disturbances. 

Pain  in  the  ear  was  generally  the  disturbing  symptom  in 
those  cases  in  which  the  foreign  body  caused  any  trouble. 
This  was  chiefly  due  to  the  irritation  of  the  lining  membrane 


CASES   OF  FOREIGN  BODIES  IN  THE  EAR.  175 

of  the  canal,  which  is  so  closely  allied  to  periosteum  in  its 
nature  as  to  be  subject  to  intense  pain.  Besides,  as  shown  by 
F.  E.  Weber,  the  pain  in  the  cartilaginous  portion  of  the  canal 
is  severe  on  account  of  the  fact,  that  the  fibrous  tissue  of  the 
cartilaginous  canal  is  fastened  to  the  squamous  portion  of  the 
temporal  bone,  above  and  behind,  by  tense  fibres.  As  has 
been  shown,  the  canal  is  very  richly  supplied  in  nerves,  and 
this  serves  to  explain  the  severe  pain  experienced  when  a 
rough  body  is  in  the  ear,  or  when  the  canal  is  abraded  by 
attempts  at  the  removal  of  a  smooth  and  harmless  one. 

Polypi  arose  five  times  in  consequence  of  the  inflammation 
of  the  ear.  Severe  hemorrhage  occurred  five  times,  and 
always  in  consequence  of  attempts  to  remove  the  foreign 
bodies. 

In  one  case  there  was  delirium,  and  in  three  cases  suppu- 
rative meningitis,  and  once  a  cerebral  abscess,  with,  of  course, 
a  fatal  result. 

The  membrana  tympani  was  perforated,  and  the  cavity  of 
the  tympanum  inflamed,  from  the  efforts  at  extraction  in  the 
three  cases  in  which  meningitis  resulted. 

In  one  case  the  patient,  a  child,  attempted  to  push  the 
foreign  body — a  piece  of  flint-stone — out  through  the  other  ear. 
Suppurative  meningitis  occurred,  and  death  resulted  in  a  few 
days.  The  stone  was  so  firmly  fixed  in  the  mastoid  cells  that 
trouble  was  experienced  in  removing  it,  even  at  the  post- 
mortem examination. 

In  one  case  on  the  section,  a  wad  of  paper  was  found  in  a 
cerebral  abscess  which  communicated  with  a  collection  of  pus 
in  the  tympanic  cavity.  It  had  probably  been  forced  there  by 
the  attempts  to  remove  it. 

The  disturbances  of  the  nervous  system  were  considerable 
in  some  cases,  and  they  throw  light  upon  the  influence  of 
chronic  aural  suppuration  upon  this  part  of  the  organism.  In 
three  cases  there  were  general  convulsions  ;  there  was  paralysis 
of  one  side  of  the  face  in  five  cases,  atrophy  of  the  arm  in  two 
cases,  twice  there  was  anaesthesia  of  the  whole  of  one  side 
of  the  body.  There  were  two  cases  of  epilepsy.  The  facial 
paralysis  was  caused  by  a  continuation  of  the  inflammation 
to  the  Fallopian  canal  and  the  facial  nerve. 


176  CASES   OF  FOREIGN  BODIES  IN  THE  EAE. 

The  convulsions  and  the  epilepsy  were  probably  caused 
by  reflex  action  through  the  medulla  oblongata,  due  to  peri- 
pheric irritation  of  the  fifth  pair  of  nerves. 

The  cases  of  atrophy  of  the  arm  and  anEesthesia  of  the 
body  are  so  imperfectly  reported,  that  Mayer  does  not  attenrpt 
any  explanation  of  them. 

Our  limits  do  not  allow  of  a  complete  transcription  of  the 
cases  which  Dr.  Mayer  has  collected  with  such  care ;  only  a 
few  of  the  more  curious  or  important  ones,  can  receive  a  fur- 
ther allusion. 

In  one  case  a  horse  coughed  some  oats  into  the  ear  of  a 
man  as  he  was  going  by  the  animal. 

Deleau,  Junior,  removed  a  foreign  body  from  the  cavity  of 
the  tympanum,  an  agate  stone,  by  an  injection  of  water 
through  the  Eustachian  tube.  The  reader  will  find  this  case 
fully  reported  in  Lincke's  collection  of  Monographs  on  the 
Ear.* 

The  case  of  atrophy  of  one  arm,  epilepsy,  anaesthesia  of 
one-half  of  the  body,  is  the  famous  one  of  Fabricius  Hildanus, 
quoted  by  Yon  Troltsch.f  The  patient,  a  young  woman  of 
18  years,  is  said  to  have  been  cured  of  all  these  symptoms  by 
the  removal  of  the  foreign  body,  a  glass  ball,  eight  years  after 
it  was  inserted. 

Handfield  Jones  X  saw  a  case  in  which  hemiplegia  with 
convulsions  arose  from  the  presence  of  insects  in  the  ear. 

Wederstrandt  §  reports  a  case  in  which  molten  lead  was 
poured  into  the  right  ear  of  a  drunken  man.  The  pain  was 
not  severe  ;  the  hearing  power  was  gone.  The  patient  was 
able  to  leave  the  hospital  in  eight  days.  The  lead  was 
not  removed,  and  severe  suppuration  occurred.  Seventeen 
months  after  he  was  in  the  same  condition,  with  paralysis 
of  the  right  orbicularis  palpebrarum  muscle ;  a  polypus  had 
grown  over  the  lead. 

In  three  of  the  cases  death  occurred,  and  in  all  of  them  it 
may  properly  be  said  to  have  been  caused  by  attempts  to 

*  Lincke's  Sammlung,  Bd.  I,  p.  154. 

f  Text-book,  American  translation,  p.  490. 

\  Sydenham  Society  Year-book,  1861. 

8  American  Journal  of  the  Medical  Sciences,  vol.  vs.. 


FATAL  ATTEMPT  TO  REMOVE  A  FOREIGN  BODY.      177 

remove  foreign  bodies,  which,  whatever  disturbances  of  the 
system  they  might  have  produced,  would  not  probably  have 
led  to  death. 

Mr.  Pilcher,  in  his  work  on  the  ear,*  reports  a  very  in- 
structive case  in  full  in  which  surgeons  of  a  London  hospital 
attempted  to  remove  from  the  ear  of  a  child  of  seven  years  of 
age,  the  head  of  a  nail,  which  they  never  saw,  but  which  they 
felt  with  a  probe. 

The  first  surgeon  to  whom  the  child  was  brought  said  he 
saw  the  head  of  the  nail,  but  he  did  not  attempt  to  remove  it 
because  four  men  could  not  hold  the  boy's  head  still.  A 
director,  dressing  forceps,  which  were  both  bent  in  the  forci- 
ble efforts,  forceps  with  hooks  were  used,  and  they  were  also 
bent  straight,  but  the  nail  could  not  be  removed.  An  incision 
was  then  made  behind  the  auricle,  and  the  meatus  was  ex- 
posed. A  search  was  then  made  for  the  nail,  with  forceps 
and  an  elevator.  Tooth  forceps  were  then  used ;  three  pieces 
of  metal,  which  appeared  to  be  pieces  of  the  nail,  were 
removed  by  these  delicate  instruments.  The  malleus  hone  was 
then  removed  by  the  forceps. 

The  patient  was  now  so  exhausted  that  "  his  pulse  could 
scarcely  be  felt,  and  his  skin  was  bedewed  with  cold  per- 
spiration." 

The  operator  then  stated  that  he  had  used  "  more  force 
than  was  warrantable."  He  thought,  however,  there  was  now 
a  large  opening  (sic)  through  which  pus  might  escape,  and 
yet  he  feared  that  a  portion  of  the  petrous  bone  might  exfo- 
liate, and  that  meningitis  and  abscess  of  the  brain  might 
occur.  He  stated  that  he  had  seen  three  or  four  cases  which 
had  terminated  in  this  manner. 

Of  course  the  little  victim  died,  and  that  too  on  the  third 
day  after  these  operative  attempts. 

The  post-mortem  examination  revealed  softening  of  the 
base  of  the  brain,  and  of  the  anterior  part  of  the  hemispheres. 

Not  a  vestige  of  the  bony  part  of  the  external  auditory 
^canal  remained,  it  having  been  removed  during  the  operation, 

*  Treatise  on  the  Ear,  American  edition,  by  George  Pilcher.    Philadelphia, 
1843.     Eeprint. 

12 


178      FATAL  ATTEMPT  TO  BEMOVE  A  FOEEIGN  BODY. 

and  the  floor  of  the  tympanum  was  also  wanting.     There  was 
considerable  pus  in  the  tympanic  cavity. 

"  The  nail  not  being  in  the  tympanum,  sections  were  made 
through  the  cochlea,  vestibule,  semicircular  canals,  and  mastoid 
cells  ;  but  there  was  no  nail  to  be  found." 

The  fact  has  already  been  alluded  to  in  this  chapter,  that 
persons  sometimes  suppose  there  is  a  foreign  body  in  the  ear, 
when  there  is  actually  none  in  it,  and  when  there  probably 
never  has  been  one  there. 

At  times  mental  delusions  occur  on  this  subject.  I  have 
seen  several  cases  of  the  kind  which  are  quite  remarkable. 

Two  cases  I  saw  at  the  New  York  Eye  and  Ear  Infirmary, 
where  the  patients,  who  were  women  of  the  lower  class  in  life, 
supposed  that  pins  were  in  the  auditory  canal.  No  amount 
of  reasoning,  nor  the  subterfuge  of  pretending  to  remove  a 
pin  from  the  ear,  by  syringing,  could  satisfy  these  females. 

In  another  case  a  woman  brought  her  son  to  my  clinic  in 
the  University  of  New  York,  and  stated  that  he  was  passing 
pieces  of  anthracite  coal  from  the  external  meatus.  She  had 
quite  a  quantity  of  coal  in  a  handkerchief,  which  she  said  had 
been  passed  from  the  ear.  Some  of  these  pieces  of  coal  were 
larger  than  the  auricle.  The  boy  agreed  with  his  mother  in 
her  insane  statements.  I  am  sorry  that  they  passed  from  my 
observation  before  I  could  fully  investigate  the  cause  or  mo- 
tive for  the  delusion. 

In  another  part  of  this  work*  allusion  will  be  again  made  to 
the  cases,  not  uncommon,  in  which  patients  with  chronic  dis- 
ease of  the  middle  ear,  and  persons  who  perhaps  were  of  sound 
mind,  firmly  believed,  in  spite  of  the  negative  result  of  my 
examinations,  that  there  was  inspissated  cerumen  in  the  audi- 
tory canal.  Indeed,  the  sensation  of  fulness  of  the  canal  in 
chronic  cases  of  disease  of  the  middle  ear,  is  often  so  decided 
as  to  render  such  a  belief  pardonable,  in  a  person  who  has  not 
full  confidence  in  the  surgeon  who  examines  the  ear. 

It  has  been  mentioned  in  the  second  chapter,  that  the  hairs 
of  the  auditory  canal  sometimes  drop  on  the  drum-head,  and 
thus  become  irritating  foreign  bodies. 

*  Chapter  on  Chronic  Non-suppurative  Inflammation. 


PART  II 


THE    MIDDLE    EAR 


CHAPTER    IX. 

ANATOMY    OF    THE    MIDDLE    EAR. 

By  far  the  greater  number  of  aural  diseases  affect  what  is 
known  as  the  middle  ear.  Of  one  thousand  cases  occurring 
in  the  private  practice  of  the  author,  eight  hundred  and  nine 
were  diseases  that  involved  these  parts  chiefly.  The  ana- 
tomy of  this  region,  therefore,  demands  a  careful  and  exact 
study. 

By  the  term  middle  ear,  we  comprehend,  strictly  speaking, 
only  the  cavity  of  the  tympanum,  the  mastoid  cells,  and  the 
Eustachian  tube  ;  but  since  the  structure  of  the  membrana 
tympani  is  in  part  identical  with  that  of  the  cavity  of  the  tym- 
panum, and  since  it  is  always  involved  in  any  considerable 
affection  of  the  middle  ear,  I  have  thought  it  wise  to  consider 
its  anatomy  in  the  same  chapter,  with  that  of  the  other  parts 
with  which  it  is  so  intimately  connected. 

THE  MEMBRANA  TYMPANI. 

The  membrana  tympani,  or  drum-head,  forms  the  bound- 
ary between  the  external  and  middle  ear.  It  partakes  of  the 
characteristics  of  these  two  parts,  in  being  composed  of  integ- 
ument and  mucous  membrane,  while  it  has  one  structure — the 
middle  or  fibrous  layer — that  is  peculiar  to  itself. 

The  upper  border  of  this  membrane  lies  7mm.  nearer  to 
the  entrance  of  the  external  auditory  canal  than  the  lower. 
The  posterior  border  is  about  5mm.  nearer  this  entrance,  or 
meatus,  than  the  anterior.  The  angle  that  the  membrana 
tympani  makes  with  the  axis  of  the  auditory  canal,  is  one  of 
about  55°.  The  inclination  of  the  two  membranes  to  an  angle 
opening  upwards  is  one  varying  from  130°  to  135°.     In  the 


182 


ANATOMY   OF   MEMBKANA   TYMPANI. 


newly  born,  the  menibrana  tympani  is  more  in  a  horizontal 
position,  than  in  the  adult,  and  lies  almost  in  the  same  line 
with  the  upper  wall  of  the  external  auditory  canal. 


Fig.  38. 


The  Bight  Temporal  Bone,  without  the  Betrous  Bortion,  in  connection  with  tke  Ossicula 
Auditus  of  a  newly  bom  Child,  seen  from  within.    After  Budinger.* 

4,  is  above  the  incus,  whose  short  process  is  directed  nearly  horizontally  backward.  5.  77ie 
long  arm  of  the  incus,  which  extends  freely  into  the  cavity  of  the  tympanum.  6.  The 
malleus,  in  articidation  tvith  the  incus.  7.  Long  process  of  the  malleus,  which  runs 
under  the  crista  tympanica,  in  a  furrow,  to  the  fissura  petroso-tympanica.  8.  The 
stapes,  in  articulation  with  the  incus. 

The  peculiar  manner  in  which  the  membrana  tympani  is 
placed  in  the  canal  causes  it  to  form  an  acute  angle  with  the 


Fig.  39. 


Left  Temporal  Bone  of  the  same  Subject  as  preceding  Figure. 
*  Atlas  des  Menschliclien  Gehororganes.     Miinchen,  1867. 


ANATOMY  OF  MEMBBA.NA  TYMPANI.  183 

lower  and  anterior  wall  of  the  auditory  canal,  but  an  obtuse 
one  with  the  upper  and  posterior  wall. 

The  general  shape  of  the  membrane  is  elliptical ;  but  the 
regularity  of  the  ellipse  is  broken  in  upon  by  the  incomplete- 
ness of  the  bony  ring  surrounding  the  membrane.  In  the 
upper  part  of  this  bony  ring  an  oyal  section  is  wanting  :  this 
space  is  known  as  the  segment  of  Bivini. 

Fig.  40. 


....■■  ,  i 

Mi 


■•  1 


Kiliii::: 


1.  The  right  temporal  bone  of  a  newly  born  child,  with  a  dried  membrana  tympani.  (After  a  pho- 
tograph. Rudinger.)  2.  The  malleus  bone,  its  apex  reaching  to  the  centre  of  the  mem- 
brane. 3.  The  long  process  of  the  incus,  seen  through  the  transparent  membrane.  It  is 
also  sometimes  observed  on  the  living  subject  in  cases  of  atrophy  of  the  membrane. 

The  long  axis  of  this  ellipsoid  runs  downwards  and  for- 
wards, the  shorter  backwards  and  downwards.  If  the  diam- 
eters of  the  membrane  are  measured  in  the  direction  of  the 
axes  of  the  ellipsoid,  that  of  the  long  axis  is  9.5-10mm.,  and 
the  horizontal  is  8m.  Measured  in  the  usual  manner,  the 
horizontal  diameter  is  8-8.5,  and  the  vertical  8.5-9mm. 

The  Kivinian  segment  is  filled  by  the  tissue  of  the  cutis 
and  the  mucous  membrane  of  the  tympanic  cavity.  The 
greater  part  of  the  fibres  of  the  tendinous  ring  of  the  mem- 
brana tympani  bend  from  their  former  course,  and  at  this 
point  turns  toward  the  short  process  of  the  malleus,  which  lies 
more  deeply  where  it  is  inserted.  The  remainder  of  the  ten- 
dinous fibres  of  the  ring  pass  upward,  and  are  lost  in  the  con- 
nective tissue  of  the  periosteum. 


184  ANATOMY  OF  MEMBRANA  TYMPANI. 

This  causes  an  irregular  triangular  space  to  be  formed, 
bounded  above  by  the  Bivinian  segment,  and  on  each  side  by 
two  bands,  which  attach  the  apex  of  the  small  process  of  the 
malleus  to  the  anterior  and  posterior  corners  of  the  osseous 
groove. 

This  space,  and  the  tissue  filling  it,  was  first  described  by 
Mr.  Henry  Jones  Shrapnell*  and  named  by  him  the  membrana 
flaccida.  It  is  often  called  Shrapnell's  membrane.  Mr. 
Shrapnell  considered  that  the  function  of  this  flaccid  mem- 
brane was  to  protect  the  more  tense  fibres  during  the  effects 
of  sudden  and  loud  sounds,  or  the  actions  of  coughing  and 
sneezing,  when  by  yielding  it  saves  the  tense  fibres  from  being 
ruptured.  In  the  hare  and  the  sheep,  that  would  be  otherwise 
defenceless  animals,  were  it  not  for  the  great  power  of  their 
ears  to  warn  them  of  approaching  dangers,  this  structure  is 
remarkably  developed. 

The  tissue  composing  Shrapnell's  membrane  is  less  tense 
than  the  remainder  of  the  membrana  tympani,  and  sometimes 
falls  in  like  a  pouch  towards  the  tympanic  cavity.  It  consists 
of  a  very  thin  layer  of  cutis  and  of  mucous  membrane.  The 
mucous  membrane  extends  to  the  osseous  edge  of  the  Bivin- 
ian segment,  and  from  here  passes  over  to  the  projecting  neck 
of  the  malleus  bone,  which  lies  opposite. 

The  existence  of  a  minute  opening  in  the  membrane — the  so-called  Bivin- 
ian foramen — has  been  warmly  disputed  from  the  time  of  its  discovery,  1717,  by 
Rivinus,f  a  professor  in  Leipsic,  until  the  present  day.  Professor  Patruban^ 
of  Vienna,  found  such  an  opening  in  300  membranes,  part  of  which  were 
healthy,  part  diseased.  He  allowed  a  fine  stream  of  quicksilver  to  pass  into 
the  so-called  canal,  and  it  always  appeared  on  the  other  side  <3f  the  membrana 
flaccida. 

Professor  Joseph  Gruberg  has  also  found  the  foramen  in  many  specimens. 
Inasmuch  as  he  often  er  found  it  in  pathological  specimens,  he  thinks  that  its 

*  London  Medical  Gazette,  vol.  10,  p.  120.  Several  German  authors  speak 
of  Shrapnell  as  Odo  Shrapnell ;  but  his  name,  as  it  appears  in  the  original  of 
his  articles,  is  as  I  have  given  it. 

f  According  .to  Von  Troltsch,  the  so-called  foramen  of  Rivinus  was  first 
discovered  by  Glaser,  in  1680,  who  was  then  professor  in  Basle.  Bochdalek, 
however,  claims  the  discovery  for  Oolle. 

%  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  1. 

§  L.  c. 


EIYINIAN  FORAMEN.  185 

size  is  at  least  increased  by  disease.  Gruber  does  not  believe  that  it  is  an 
opening  always  to  be  found  ;  but  that  it  is  one  frequently  observed,  and  that  it 
would  be  an  interesting  inquiry  as  to  how  far  it  is  the  result  of  disease. 

Dr.  Politzer*  thinks  that  the  Kivinian  foramen  is  a  constant  appearance,  not 
an  anomaly  or  result  of  disease. 

Hyrtlf  denies  the  existence  of  the  membrane,  and  says  that  he  has  never 
found  it,  either  on  the  adult  or  infantile  cadaver.  The  ability  to  blow  tobacco- 
smoke  from  the  ears  is  the  result,  he  thinks,  of  a  want  of  development  in  the 
upper  part  of  the  membrane. 

Professor  Bochdalek,  of  Prague,  rediscovered  the  opening  at  the  upper 
margin  of  the  membrana  tympani,  one-third  to  three-fourth  lines,  from  the 
edge,  and  reopened  the  discussion  which  Hyrtl  seemed  to  bave  closed. 

If  the  Rivinian  foramen,  or  canal,  does  exist  in  the  membrana  fiaccida,  it  is 
so  small  that  only  a  fine  bristle,  or  hair,  will  pass  in  it,  and  the  anatomist 
must  sometimes  persevere  for  hours  with  a  magnifying-glass,  in  order  to  find 
it.  Bochdalek:):  describes  his  discovery  of  the  opening  as  follows :  "  To  my 
great  astonishment  I  saw,  by  means  of  a  magnifying-glass,  on  the  posterior 
portion  of  a  small  depression  on  the  membrana  tympani,  and  a  little  behind 
the  malleus,  a  very  small  canal,  in  which  was  perceived,  although  very 
indistinctly,  a  punctiform  opening.  By  means  of  a  very  fine  bristle  I  suc- 
ceeded in  entering  a  narrow  groove,  not  more  than  one-third  of  a  line  long, 
which  ran  in  an  oblique  direction  from  above  downward,  and  somewhat  ante- 
riorly, into  the  cavity  of  the  tympanum,  so  that  the  bristle  passed  immediately 
beneath  the  handle  of  the  malleus,  and  just  as  closely  beneath  the  chorda  tym- 
pani. On  pushing  the  bristle  still  farther,  it  passed  under  the  tendon  of  the 
inner  muscle  of  the  malleus,  and  struck  on  the  inner  wall  of  the  cavity  of  the 
tympanum." 

Dr.  Bochdalek  also  found  the  foramen  in  the  opposite  membrane  of  the 
same  subject,  as  well  as  in  sixty-three  other  preparations  of  the. membrana 
tympani.  Forty  of  them  were  from  fresh  subjects,  the  remainder  had  been 
preserved  in  alcohol.  In  two  cases  only  the  opening  was  not  found.  In  both 
these  cases  morbid  changes  (thickening  ?)  had  occurred  in  the  drum-head. 

Kessel§  believes  that  the  foramen  is  the  result  of  inflammation.  He  says 
that  he  has  convinced  himself  of  the  correctness  of  this  view,  by  dissections 
and  by  examination  of  the  living  subject  at  Gruber's  clinic. 

The  author  believes  in  the  existence  of  the  foramen  of  Eivinus,  from  the 
clinical  fact  that  he  has  heard  a  whistling  sound,  seemingly  through  the  mem- 
brana tympani,  in  several  cases,  when  the  Valsalvian  experiment  was  made, 
when  neither  he  nor  other  observers  could  detect  the  slightest  opening  with 
the  eye.  I  have  also  been  startled,  in  one  or  two  instances,  on  blowing  my 
nostrils  violently,  by  hearing  the  air  whistle  through  the  drum-head,  as  it 
seemed.  On  one  occasion,  I  immediately  consulted  a  friend  who  has  large 
experience  in  examining  the  membrana  tympani,  and  he  decided  that  it  was 

*  L.  c. 

f  Anatomie  des  Menschen,  p.  520. 

%  Prag.  Viertel.  Jahrschrift,  January,  1866. 

§  Strieker's  Hand-book  of  Histology,  p.  953. 


186  ANATOMY  OF  MEMBEANA  TYMPANI. 

not  perforate,  as  did  several  others  who  soon  examined  the  ear.  Indeed,  I 
have  never  suffered  from  any  disease  of  the  ear  that  led  me  to  suppose  the 
drum-head  could  he  perforate. 

I  cannot  escape  the  subjective  conviction,  however,  that  the  foramen  of 
Rivinus  exists,  and  that  air  may  be  occasionally  heard  to  whistle  through  it, 
although  the  opening  itself  cannot  he  seen. 

Mr.  Wharton  Jones*  described  the  circular  and  radiating 
fibres  of  the  membrana  tympani  in  his  article  on  the  organ  of 
hearing. 

Sir  Everard  Homef  supposed  that  these  fibres  were  muscular,  and  he 
thought  that  by  this  muscle  "  accurate  perceptions  of  sounds  were  conveyed  to 
the  internal  organ."  Mr.  Home  admitted  that  the  muscles  of  the  malleus 
stretched  and  relaxed  the  membrana  tympani,  but  only  in  order  to  bring  the 
radiated  muscle  into  a  state  capable  of  acting. 

Mr.  Home  reports  a  case  of  double  hearing,  which  has  been  before  alluded 
to  (see  Chapter  VI.),  and  he  explains  it  by  a  defective  action  of  the  radiated 
muscle,  which  was  not  exerted  with  the  same  quickness  and  force  in  one  ear 
as  in  the  other,  so  that  the  sound  was  half  a  note  too  low,  as  well  as  later  in 
being  impressed  upon  the  organ. 

The  patient,  judging  from  the  history,  evidently  had  a  catarrh  of  the  tym- 
panic cavity,  and  the  double  hearing  probably  arose  from  unequal  pressure  on 
the  labyrinths. 

The  objects  in  the  membrana  tympani  which  first  strike 
the  attention  of  the  observer  are  the  handle,  or  long  process 
of  the  malleus  bone,  and  the  triangular  spot  of  light.  I  am 
now  speaking  of  the  membrane,  when  viewed  through  the 
auditory  canal.  When  this  is  detached,  the  reflection  called 
the  light  spot,  is  not  seen,  because  one  of  the  conditions 
for  its  formation  is  removed,  as  is  also  true,  to  a  certain 
extent,  of  a  membrane  seen  after  death,  when  the  tissues  are 
macerated. 

The  long  process  of  the  malleus,  also  called  the  handle  or 
manubrium  of  the  malleus,  divides  the  membrane  into  two 
parts.  The  anterior  part  is  larger  than  the  posterior.  The 
attachment  of  the  malleus  between  the  layers  of  the  drum- 
head will  be  described  in  the  description  of  these  parts. 

At  the  extremity  of  the  handle  of  the  malleus  is  situated 
the  apex  of  the  light  spot.     This  point  is  also  the  place  of 

*  Cyclopaedia  of  Anatomy  and  Physiology,  vol.  ii. 

f  Philosophical  Transactions  of  the  Royal  Society  of  London,  1800.    Part  I. 


THE  TRIANGULAR  LIGHT  SPOT.  187 

greatest  concavity  of  the  outer  surface  of  the  drum-head, 
and  is  called  the  umbo  (boss  of  a  shield),  or  navel  of  the 
membrane. 

The  light  spot,  as  will  be  seen  in  the  chapter  on  chronic 
non-suppurative  disease  of  the  middle  ear,  is  one  of  the  im- 
portant standpoints  for  the  diagnosis  of  certain  affections  of 
the  middle  ear.  The  study  of  the  conditions  necessary  to  its 
formation  is  therefore  of  importance. 

Fra.  41.  Fig.  42. 


View  of  Membrana  Tympani,  showing  Handle  of  Malleus  and  Triangular  Spot  of  lAght. 

An  account  of  the  normal  color  of  the  membrana  tympani 
will  be  found  in  the  chapter  on  Chronic  Non-suppurative  In- 
flammation. Until  the  investigations  of  Von  Troltsch  and 
Politzer,  this  was  described  as  seen  in  the  dead  subject ;  but 
the  post-mortem  appearances  of  this  membrane  are  no  guide 
to  its  appearance  on  the  living  subject.  The  ordinary  breadth 
of  the  light  spot,  at  its  base,  is  from  one  and  a  half  to  two 
millimetres. — (Politzer.)  It  is  sometimes  interrupted  in  its 
continuity. 

The  chief  causes  of  the  existence  of  the  light  spot,  accord- 
ing to  Politzer,*  are  the  inclination  of  the  membrane  to  the 
axis  of  the  external  auditory  canal,  and  the  concavity  pro- 
duced by  the  traction  of  the  handle  of  the  malleus. 

If  light  be  thrown  upon  a  dried  preparation  of  the  human 
ear,  as  in  the  examination  of  the  living  subject,  through  the 
auditory  canal,  the  light  spot  will  be  found  in  the  same  posi- 
tion as  it  is  seen  in  life.  It  is  also  displaced  very  little  by  mov- 
ing the  eye  in  different  directions,  because  the  axis  of  vision 

*  The  Membrana  Tympani,  p.  26.    Mathewson  and  Newton's  translation. 


188  THE   TRIANGULAR  LIGHT  SPOT. 

corresponds  so  nearly  to  the  axis  of  the  meatus,  that  the  light 
spot  can  change  very  little  with  respect  to  the  inclination  to 
the  membrana  tympani. 

No  light  would  be  reflected  to  the  eye  if  the  membrane 
were  a  plane  surface ;  for,  with  its  inclination  to  the  auditory 
canal,  all  rays  thrown  upon  it  would  be  reflected  against  the 
anterior  and  lower  wall  of  the  canal.  In  consequence,  how- 
ever, of  the  inward  curvature  from  the  traction  of  the  handle 
of  the  malleus,  its  parts  undergo  such  a  change  of  inclination 
that  the  anterior  portion  stands  directly  at  right  angles  to  the 
axis  of  vision  of  the  observer,  and  the  light  thrown  upon  it  is 
reflected  back  to  the  eye. 

Politzer  proved  the  correctness  of  this  opinion  by  stretch- 
ing an  animal  membrane  over  a  large  ring,  and  giving  it  the 
inclination  of  the  membrana  tympani.  No  reflection  will  be 
perceived  until  the  central  portion  is  pressed  inward,  or  made 
concave  by  traction  from  behind  it. 

Helmholtz*  also  states  that  the  triangular  spot  of  light  is 
due  to  reflection.  Voltolini  t  claims  that  the  light  spot  may 
be  seen  when  no  auditory  canal  is  present ;  indeed,  even  when 
the  membrane  is  completely  removed.  This  seems  to  me  to 
be  a  mistake ;  for  while  there  is  a  reflex  from  any  generally 
convex  brilliant  membrane,  such  as  the  drum-head,  although 
it  has  a  central  concavity,  there  is  no  such  triangular  and 
fixed  one,  as  when  the  auditory  canal  is  present,  and  this  is 
the  whole  point  of  the  theory  of  Politzer. 

Voltolini  is  correct,  however,  in  calling  attention  to  other 
modifications  of  the  light  spot,  than  its  inclination  in  the  audi- 
tory canal.  If  it  become  thickened,  inflamed  or  infiltrated ; 
in  other  words,  if  from  mechanical  or  chemical  causes  it  cease 
to  be  a  brilliant  membrane,  and  it  does  not  reflect  light  as 
well  as  formerly,  the  light  spot  will  no  longer  be  triangular  in 
shape,  and  perhaps  not  exist  at  all ;  but  neither  the  concavity 
nor  polish  of  the  membrane  have  all  to  do  with  the  existence 
of  the  light  spot,  as  Voltolini  asserts.  Any  person  can  prove 
this  for  himself  by  a  few  simple  experiments,  with  a  membrane 
stretched  over  the  end  of  a  tube. 

*  Monatsschrift  ftir  Olirenlieilkunde,  Jalirgang  VI.,  No.  8. 
f  L.  c. 


LAYEBS  OF  THE  MEMBKANA  TYMPANL 


189 


The  light  spot  depends  upon  three  factors,  viz. : 
I. — The  inclination  of  the  membrana  tympani  to  the 
auditory  canal. 
II. — The  traction  of  the  malleus,  which  renders  it  concave 

at  the  center. 
HI.  Its  polish  or  brilliancy. 


THE  LAYERS  OF  THE  MEMBRANA  TYMPANI. 


The  membrana  tympani.is  not  quite  0.1  millimetre  in  thick- 
ness (Henle) — about  as  thick  as  very  fine  letter-paper  or  gold- 
beater's skin  (Yon  Troltsch).  This  thickness  varies  within 
small  limits. 

There  are  three  layers  in  the  structure  of 
the  membrana  tympani. 

1.  A  thin  layer  of  integument. 

2.  A  fibrous  layer.  This  layer  forms  the 
principal  thickness  of  the  membrane. 

3.  A  mucous  layer  continuous  with  that 
of  the  tympanic  cavity. 

The  first  or  integumentary  layer  of  the 
membrana  tympani  has  none  of  the  hairs  or 
glands  of  the  lining  of  the  canal,  of  which 
it  is  a  direct  continuation.  The  papillae  are 
found  as  far  as  the  short  process  of  the  mal- 
leus. 

The  epidermal  cells,  the  cuticle  and  corium 
diminish  gradually  in  thickness  from  the  peri- 
phery towards  the  handle  of  the  malleus  ;  they 
then  increase  and  are  thickest  on  the  outer 
edge  of  this  bone. 

The  fibrous  layer  consists  of  lamellae,  each  one  of  which 
forms  a  mesh-work  of  smooth  fibres  with  narrow,  almost 
fissure-shaped  apertures.  The  fibres  have  an  average  breadth 
of  0.01  millimeters. 

The  majority  of  the  fibres  run  to  the  malleus  in  a  radiating 
or  circular  direction.  A  small  number  of  them,  however,  run 
in  different  directions  between  these  two  sets  of  fibres.     The 


Vertical  Section  of  Fi- 
brous Layer  of  the 
Membrana  Tympani. 
After  Henle. 


190  LAYEES   OF  THE  MEMBEANA  TYMPANI. 

radiating  fibres  are  external,  beneath  the  cutis,  the  circular 
next  to  the  mucous  membrane. 

The  fibres  of  the  membrana  tympani  are  sharply  outlined 
and  opaque,  flattened  on  the  sides,  swelling  out  in  the  middle. 
They  are  from  0.0036  to  0.0108  millimeters  in  thickness. 
Sometimes  they  appear  to  be  homogeneous,  but  they  are 
actually  fibrillated.  Chromic  acid,  chloride  of  gold,  and  osmic 
acid  bring  out  the  fibrillated  structure. — {Kessel.) 

The  fibrous  layer  might  be  well  described,  according  to 
Kessel,  "  as  a  deep  layer  of  the  corium  changed  and  adapted 
for  physiological  purposes."  The  slits  or  apertures  which 
have  been  spoken  of  are  usually  empty  and  appear  to  glisten, 
or  on  their  edges  they  are  covered  by  a  finely  granular 
mass. 

Cells  are  sometimes  found  which  fill  them  exactly.  Yon 
Troltsch  called  these  cells  the  corpuscles  of  the  membrana 
tympani.  The  larger  spaces  contain  encapsulated  nuclei,  and 
are  frequently  filled  with  amseboid  cells. 

On  the  periphery  the  thin  layers  of  the  membrana  tym- 
pani interweave,  leaving  large  and  small  spaces  between  the 
fibres  for  the  passage  of  vessels,  and  form,  by  union  with  the 
outer  and  internal  layers,  the  "tendinous  ring,"  which  is 
attached  by  means  of  a  thin  periosteum  to  the  osseous  ring, 
or  annidus  tympanicus.     (See  engraving  on  page  201.) 

All  the  layers  of  the  fibrous  layers  are  united  to  the  osseous 
ring.  Kessel  confirms  Gruber's  observation  that  the  circular 
fibres  may  be  followed  into  the  tendinous  ring  ;  but  he  adds, 
"  these  fibres  singly,  and  at  some  distance  from  each  other, 
pass  off  again  from  the  ring  at  very  acute  angles,  collect 
together  and  reach  nearly  as  great  thickness  as  that  which 
results  from  the  union  of  the  fibres,  coming  from  the  epider- 
mis, cutis  and  mucous  membrane."  The  tension  of  these 
fibres  causes  a  convexity  of  the  radii  of  its  surface  towards 
the  meatus  externus,  giving  the  membrane  a  general  convexity. 
The  circular  fibres  do  not  exist  on  the  lower  third  of  the 
handle  of  the  malleus  and  the  adjacent  parts. 

The  handle  of  the  malleus  is  attached  to  the  fibrous  layer 
between  the  radiating  and  circular  fibres.  According  to  Gru- 
ber,  there  is  a  cartilaginous  formation,  which  begins  over  the 


STEUCTUEE   OF  MEMBEANA  TYMPANI.  191 

short  process  of  the  malleus,  and  extends  |mm.  below  the 
handle.  This  is  firmly  united  below  ;  but  above,  at  the  short 
process,  there  is  a  kind  of  a  joint,  the  cavity  of  which  is  filled 
with  synovial  fluid. 

Prussak,  Moos  and  Xessel,*  say  that  while  this  cartilage 
exists — that  is  to  say,  that  a  third  of  the  short  process  is  of  car- 
tilage— it  passes  into  the  osseous  portion  without  interruption. 
There  is  also,  according  to  Prussak  and  Moos,  a  thin  layer 
of  cartilage  cells  under  the  periosteum  of  the  handle  of  the 
malleus  not  only  in  infants,  but  also  in  adults. 

Kessel  found  on  sections  of  the  ossicles  in  embryos  from 
three  to  nine  months,  that  the  malleus  is  surrounded  by  an 
independent  periosteum  distinct  from  the  elements  of  the 
fibrous  layer,  and  only  united  with  the  mucous  layer  by  a 
duplicature  of  the  mucous  membrane.  In  place  of  the  short 
process  there  is  a  quantity  of  glistening  nucleated  cells  under 
the  periosteum  and  in  the  tissue  duplicature.  These  elements 
remain  through  life  as  cartilage  cells,  and  form  a  a  solid  mass 
with  the  osseous  portion  of  the  small  process. 

At  birth  the  malleus  is  only  closely  united  to  the  mem- 
brana  tympani  at  two  points — at  the  short  process,  and  at  the 
lower  third  of  the  handle.  The  fibrous  layer  is  united  with 
the  periosteum  of  the  upper  portion  of  the  handle  of  the 
malleus  only  by  loose  connective  tissue,  so  that .  a  slight 
motion  of  the  bone  is  possible  at  this  point  without  an  arti- 
culation. 

The  mucous  layer  consists  of  an  epithelium  and  a  fibrous 
frame-work  beneath  it.  On  the  inner  side  of  the  membrane, 
at  the  upper  part  of  its  posterior  half,  is  found  an  irregu- 
larly triangular  fold,  3  to  4mm.  high  and  4m.  broad,  which 
arises  close  behind  the  annulus  tympanicus,  and  extends  to 
the  handle  of  the  malleus.  A  cavity  is  thus  formed  which 
opens  below,  which  is  called  by  Von  Tr61tsch,f  who  described 
it,  "  the  posterior  pouch  "  of  the  membrana  tympani. 

The  best  view  of  this  duplicature  is  seen  by  viewing  the 

*  Strieker's  Hand-Book,  p.  955. 

f  Von  Troltsch,  Lehrbuch  der  Ohrenheilkunde  Vierte  Aufgabe,  1868, 
p.  38. 


192  BLOOD-VESSELS  OF  MEMBBANA  TYMPANI. 

membrana  tympani  from  tlie  inside,  while  it  is  still  in  position, 
after  the  roof  of  the  tympanic  cavity  has  been  removed,  and 
the  incus  detached  from  the  malleus;  but  it  may  even  be 
seen  from  the  outer  surface,  by  a  good  illumination,  in  the 
living  subject.  The  tissue  of  the  pocket  is  the  same  as  that 
of  the  fibrous  layer. — ( Von  Troltsch.) 

A  similar  space  is  found  in  front  of  the  malleus,  but  this 
is  not  formed  by  a  duplicature  of  the  fibrous  layer,  but  by  a 
small  long  process  turned  towards  the  neck  of  the  malleus, 
by  the  mucous  membrane  that  lines  the  tympanic  cavity,  and 
by  all  the  parts  that  enter  and  leave  the  Glaserian  fissure,  by 
the  bony  process  of  the  malleus,  by  the  anterior  ligament  of 
the  malleus,  the  chorda  tympani  nerve,  and  the  inferior  tym- 
panic artery. 

Villous  processes  are  found  on  the  edge  of  the  mucous 
membrane,  especially  in  children.  These  processes  are  also 
found  on  the  pouch  of  Von  Troltsch  and  on  the  malleus.  They 
are  covered  by  flattened  epithelium,  and  are  composed  of  con- 
nective tissue  in  which  there  are  capillary  loops. 

BLOOD-VESSELS. 

According  to  the  recent  investigations  of  Kessel,  there  are 
blood-vessels,  nerves,  and  lymphatics  in  all  the  layers  of  the 
membrana  tympani.  It  had  been  previously  taught  by  nearly 
all  the  writers,  that  there  were  no  blood-vessels  or  nerves  in 
the  fibrous  layer  of  the  drum-head,  although  according  to 
Gerlach,  there  was  a  capillary  anastomosis  between  the  mu- 
cous membrane  and  the  cutis  on  the  periphery  of  the  middle 
or  fibrous  layer.  Kessel*  also  claims  to  have  first  described 
the  lymph  vessels. 

According  to  Kessel,  there  is  a  direct  passage  of  blood- 
vessels from  the  outer  layer  of  the  membrana  tympani  to  the 
cavity  of  the  tympanum  ;  a  complete  capillary  net-work  in  the 
fibrous  layer  communicates  with  the  cutis  and  the  mucous 
membrane. 

The  blood-vessels  that  pass  from  the  auditory  canal  down 

*  L.  c,  p.  958. 


NEEVES  OP  MEMBEANA  TYMPANI.  193 

upon  the  membrana  tympani,  come  from  the  deep  auricular 
artery,  which  is  a  branch  of  the  internal  maxillary. 

Those  on  the  mucous  membrane  arise  from  the  vessels  of 
the  tympanic  cavity. 

The  blood  supply  of  the  outer  layer  of  the  membrane  may 
be  very  readily  traced  in  many  cases  of  inflammation,  or  after 
injecting  the  canal  with  warm  water.  The  whole  circumfer- 
ence of  the  membrane  is  usually  found  injected  in  connection 
with  redness  of  the  lower  part  of  the  canal.  Larger  vessels 
run  immediately  behind  the  handle  of  the  malleus  to  the 
umbo,  where  they  pass  off  in  radii  to  the  edge. 


NERVES  OF  THE  MEMBRANA  TYMPANI. 

Nerves  are  found  in  each  layer  of  the  membrana  tympani. 
The  larger  nerve-trunks  accompany  the  chief  vessels.  They 
divide  as  these  do,  and  frequently  unite  together  like  the 
capillaries.  They  form  thick  networks  under  the  epithelium 
of  the  cutis,  and  also  under  that  of  the  mucous  membrane.  A 
fundamental  plexus,  a  capillary  plexus  near  the  vessels,  and  a 
sub-epithelial  plexus  may  be  distinguished. 

The  chief  nerve-trunk  consists  of  medullated  fibres,  which  is 
provided  with  a  sheath  of  Schwann,  and  lies  on  the  boundary 
between  the  cutis  and  the  fibrous  layer.  It  passes  on  to  the 
membrane  at  the  upper  part  of  the  posterior  segment.  Be- 
sides this  chief  trunk,  several  small  branches  enter  the  mem- 
brane at  different  parts  of  the  periphery. 

In  addition  to  the  openings  in  the  fibrous  layers,  with  their 
contents,  Kessel  found  a  large  number  of  nucleated  swellings, 
provided  with  two  or  more  processes,  that  unite  with  the 
nerve-fibres,  and  which  lie  above  and  between  the  single 
fibrous  layers. 

The  greater  part  of  the  cell  elements  found  between  the 
fibres  of  the  fibrous  layer,  must  be  considered,  according  to 
Kessel,  as  belonging  to  the  blood  and  lymph  vessels,  and  to 
the  nervous  system.* 

*  Kessel,  in  Strieker'*!  Handbook,  p.  962. 


194 


NERVES  OF  MEMBRANA  TYMPANI. 


The  nerves  of  the  mucous  membrane  of  the  membrana 
tympani  are  also  more  numerous,  according  to  the  author 
from  whom  I  have  just  quoted,  than  has  been  hitherto  sup- 
posed.    There  is  a  plexus  near  the  vessels,  and  a  sub-epith-" 


Fig.  44. 


The  Membrana  Tympani,  in  connection  with  the  Ossicula  Auditus  of  the  Right  Temporal 
Bone.    From  a  Plwtograph.    Rudinger. 

1.  Transverse  section  of  the  fossa  sigmoidea,  in  which  is  the  transverse  sinus.  2.  Lower  sec- 
lion  of  the  transverse  sinus.  3.  Inner  side  of  the  transverse  wall  thrown  back,  which 
causes,  4,  tlie  emissarius  mastoideus  to  be  opened.  5.  Carotid  canal.  6.  The  membrana 
tympani  connected  to  the  mucous  membrane  of  the  cavity  of  the  tympanum.  7.  The  mal- 
leus on  the  anterior  and  upper  portion  of  the  handle  ;  the  pockets  of  the  membrana  tym- 
pani are  seen.  8.  The  divided  tendon  of  the  tensor  tympani  muscle.  9.  The  incus. 
10.  Stapes  lying  by  the  stapedius  muscle,  on  the  pyramid,  which  is  opened.  11.  /Stape- 
dius muscle.    12.  Section  of  facial  nerve.    13.  Chorda  tympani  nerve. 


lial  plexus.  The  former  accompanies  the  lymph  rather  than 
the  blood-vessels.  It  receives  its  fibres,  in  part,  from  threads 
of  the  tympanic  plexus,  which  pass  on  to  the  membrane, 
with  the  mucous  membrane,  from  different  parts  of  the  peri- 


LYMPH  VESSELS   OP  MEMBRANA  TYMPANI.  195 

phery,  and  partly  from  the  nerves  of  the  cutis,  passing 
through  the  fibrous  layer.  The  sub-epithelial  plexus  is  a 
fine  network  directly  under  the  epithelium,  which  it  supplies 
with  threads.* 

The  outer  nerve  supply  of  the  membrana  tympani  is  from 
the  fifth  pair.  The  main  trunk  is  a  branch  of  the  superficial 
temporal  nerve,  from  the  third  branch  of  the  trifacial  or  fifth 
nerve. 

The  chorda  tympani  nerve  runs  along  the  inner  surface  of 
the  membrana  tympani,  but  gives  no  branches  to  it. 

LYMPH  VESSELS. 

They  are  arranged  in  three  layers,  like  those  of  the  blood- 
vessels. The  first  layer  belongs  to  the  cutis,  the  second  to 
the  fibrous  layer,  and  the  third  to  the  mucous  membrane.  In 
the  cutis  they  form  a  very  fine  network,  immediately  under 
the  rete  Malpiglm.  This  network  passes  over  the  capillaries  at 
many  points.  They  gradually  pass  into  large  capillaries, 
which  often  interlace  with  the  blood  capillaries,  and  finally 
unite  in  independent  and  larger  trunks.  These  run  either 
posteriorly  and  above,  or,  exactly  like  the  blood-vessels,  pass 
at  various  points  to  the  periphery  and  to  the  auditory  canal. 

In  the  mucous  membrane,  also,  there  is,  although  not  in 
large  number,  a  sub-epithelial  network,  lying  near  the  tendin- 
ous ring.  They  are  distinguished  from  the  blood  capillaries 
of  the  same  width  by  their  manifold  dilatations.f 

THE  CAVITY  OP  THE  TYMPANUM. 

The  tympanum  [drum),  cavity  of  the  tympanum,  or  drum 
of  the  ear,  is  the  irregular,  air-containing  space  lying  beyond 
the  membrana  tympani.  The  mastoid  cells,  also  containing 
air,  and  lying  in  the  mastoid  portion  of  the  temporal  bone, 
are  connected  with  the  tympanum  at  its  upper  and  posterior 
part ;  while  the  Eustachian  tube  permits  the  entrance  of  air 
into  the  cavity  through  the  upper  part  of  its  anterior  wall. 

*  Kessel,  p.  963. 

\  Kessel,  Handbuch  der  Lehre  von  dem  Geweben,  p,  851. 


196 


THE  CAVITY  OF  THE  TYMPANUM. 


The  points  to  be  noted  in  the  description  of  the  tympanic 
cavity  are  indicated  in  the  following  scheme  : 


THE 

TYMPANUM 

-presents  for  ex- 
amination Us 


1.  Dimensions. 


2.  Walls. 


3.  Ossicles. 


the  Anterior, 
the  Posterior, 
the  Outer, 
the  Inner, 
the  Upper, 
the  Lower. 

{Malleus. 
Incus. 
Stapes. 

Ligaments  of  mov- 
able joints 


4.  Ligaments. 


Ligaments   of   im- 
movable joints. 


j  Tensor  Tympani. 
1  Stapedius. 

6.  Mucous  Membrane. 


Malleus — Incus. 
Incus — Tympanum. 
Incus — Stapes. 

'  Obturator  Stapedis. 
Mallei  Superior. 
Mallei  Anterior. 
Incudis  Superior. 


5.  Muscles. 


7.  Vessels. 

8.  Nerves. 


1.  The  dimensions  of  the  tympanum,  like  those  of  the  exter- 
nal auditory  meatus,  vary  much  in  different  individuals.  The 
following  table  shows  about  the  average  diameters,  as  given 
by  Yon  Troltsch  :* 


Antero-posterior  diameter 

Vertical  " 

«  it 

Transverse  " 


13mm. 

at  anterior  part,  5  to  8mm. 

at  posterior  "  15mm. 

an  anterior  "  3  to  4.5mm. 

opposite  the  drum-head,  2mm. 


2.  The  anterior  ivaU  presents,  at  its  upper  part,  an  opening 
of  considerable  size — the  tympanic  orifice  of  the  Eustachian 
tube.     Below  this  is  a  strong  bony  plate. 


*  Text-book,  American  translation,  p.  171. 


CAVITY  OF  THE  TYMPANUM. 


197 


The  posterior  wall  separates  the  cavity  of  the  tympanum 
from  the  mastoid  cells.  The  opening  into  the  cells  is  at  its 
upper  part,  close  under  the  roof,  and  considerably  higher  than 
the  orifice  of  the  Eustachian  tube. 


Fig.  45. 


The  Bight  Temporal  Bone,  with  the  Membrana  Tympani  and  Ossicula  Auditus  of  an  Adult. 

1.  Squamous  portion — under  figure  1  the  sulcus  of  the  transverse  sinus  runs  dmvnward.  2.  A 
bristle  passes  through  the  mastoid  foramen.  3.  Mastoid  cells.  4.  Antrum  of  the  mastoid, 
communicating  both  with  the  mastoid  cells  and  with  the  tympanic  cavity.  5.  Styloid 
process.  6.  Membrana  tympani ;  a  point  of  mucous  membrane  of  the  tympanic  cav- 
ity is  seen  under  the  number  6.  7.  The  malleus.  Under  the  chorda  tympani  we  see 
the  divided  tendon  of  the  tensor  tympani  muscle.  8.  The  incus.  9.  The  short  process.  10. 
TJie  chorda  tijmpani  nerve.  11.  The  stapes.  12.  Stapedius  muscle.  13.  Facial  nerve.  14. 
Stapedius  nerve,  branch  of  facial.  The  relations  of  the  mastoid  cells  to  the  cavity  of  the 
tympanum  and  tlie  relations  of  the  former  to  the  transverse  sinus  are  well  shown.  After 
Budinger. 


The  outer  wall  of  the  tympanic  cavity  is  composed,  for  the 
most  part,  of  the  membrana  tympani ;  but  it  extends  much 
further  backwards  than  the  membrane,  and  contains  three 
small  openings  :  the  aperture  of  the  iter  chordse  posterius,  the 


198  CAVITY   OF  THE  TYMPANUM. 

Glaserian  fissure,  and  the  aperture  of  the  iter  chordae  ante- 
rius. 

The  opening  of  the  iter  chordae  posterius  is  on  a  level  with 
the  centre  of  the  membrana  tympani,  and  close  to  the  margin 
of  the  membrane,  and  gives  entrance  to  the  chorda  tympani 
nerve.  The  nerve  then  runs  upwards  under  the  long  process 
of  the  incus,  on  the  free  margin  of  the  posterior  pocket  of  the 
membrana,  then  forwards  across  the  neck  of  the  malleus,  and 
finally  enters  the  iter  chordce  anterius,  or  canal  of  Huguier. 
The  Glaserian  fissure  opens  above,  and  in  front  of,  the  mem- 
brana tympani ;  while  just  above  it  is  seen  the  aperture  of  the 
iter  chordae  anterius. 

The  inner  wall  of  the  tympanum  is  the  outer  boundary  of 
the  labyrinth,  and  consists  of  bone.  It  has  two  small  aper- 
tures closed  by  membranes.  The  upper  and  larger  opening  is 
called  the  fenestra  ovalis,  or  oval  window,  and  leads  into  the 
vestibule  ;  while  the  lower  and  smaller  one  is  called  the  fenes- 
tra rotunda,  or  round  window,  and  communicates  with  the 
cochlea.  The  former  is  closed  by  the  periosteum  of  the  vesti- 
bule, to  which  the  base  of  the  stapes  is  attached.  The  fenes- 
tra rotunda  lies  below  the  fenestra  ovalis,  and  is  closed  by  the 
membrana  tympani  secundaria.  Both  these  openings  may  per- 
haps more  properly  be  called  canals,  since  they  have  consid- 
erable depth,  the  membranes  which  close  them  lying  at  their 
inner  extremities. 

In  front  of  the  fenestras,  and  partly  between  them,  lies  the 
promontory,  a  projection  of  the  outermost  turn  of  the  cochlea. 
Upon  it  may  be  seen  three  shallow  grooves  for  branches  of 
the  tympanic  plexus.  In  front  of  the  promontory  the  inner 
wall  of  the  tympanum  consists  of  a  very  thin  plate  of  bone 
separating  this  cavity  from  the  carotid  artery.  This  plate  is 
pierced  by  many  minute  openings  for  vessels  and  nerves,  and 
has,  besides,  many  irregularities  on  its  tympanic  surface. 

Just  above  and  behind  the  fenestra  ovalis,  is  a  slight 
rounded  ridge,  corresponding  to  the  aquceductus  Fallopii,  which 
gives  passage  to  the  facial  nerve.  This  canal  is  covered  by 
an  extremely  thin  plate  of  bone.  Behind  and  below  the  fen- 
estra ovalis  is  the  pyramid,  a  hollow,  bony  projection  contain- 
ing the  stapedius  muscle.     The  bottom  of  this  cavity  of  the 


CAVITY  OF  THE  TYMPANUM.  199 

pyramid  is  in  communication  with  the  aqusoductus  Fallopii  by- 
means  of  a  minute  canal.  Just  behind  the  ridge  of  the  Fallo- 
pian canal,  and  about  on  a  level  with  the  fenestra  ovalis,  is 
seen  a  hard,  smooth,  bony  surface,  which  corresponds  to  the 
external  or  horizontal  semicircular  canal  of  the  labyrinth. 

The  upper  wall,  or  roof  of  the  tympanum,  is  the  partition 
between  this  cavity  and  that  of  the  cranium.  Its  thickness 
and  density  vary  considerably  in  different  subjects.  It  is 
sometimes  very  thin  and  porous,  or  entirely  wanting,  so  that 
the  tympanum  forms  a  part  of  the  cranial  cavity. 

The  lower  wall,  or  floor  of  the  tympanum,  separates  this 
cavity  from  the  jugular  vein.  Like  the  roof,  it  varies  greatly 
in  thickness,  being  sometimes  wholly  membranous.  It  is  very 
irregular  on  its  upper  or  tympanic  surface ;  and  lying  much 
below  some  points  in  the  floor  of  the  external  auditory  mea- 
tus, and  below  the  orifices  of  the  Eustachian  tube  and  mastoid 
cells,  it  is  usually  covered,  in  cases  of  purulent  affections  of 
the  middle  ear,  by  a  large  quantity  of  pus.  It  is  perforated 
by  the  glosso-pharyngeal  nerve  and  a  minute  vessel. 

Studied  with  an  eye  to  pathological  conditions,  some  of 
these  walls  present  very  important  relations.  Thus  the  roof 
of  the  tympanum  lies  in  contact  with  the  meninges  of  the 
brain,  so  that  in  caries  of  this  wall  the  patient  may  die  of 
purulent  meningitis  or  cerebritis.  Again,  caries  of  the  lower 
wall  may  be  followed  by  phlebitis  of  the  jugular  vein  ;  while 
caries  of  the  inner  wall  has  sometimes  caused  destruction 
of  the  coats  of  the  carotid  artery  and  fatal  hemorrhage, 
also  a  suppurative  inflammation  of  the  labyrinth,  with  exten- 
sion into  the  cavity  of  the  skull.  It  is  easy  to  see,  too,  how 
even  a  non-suppurative  inflammation  of  the  tympanum  may 
affect  the  facial  nerve,  since,  during  a  part  of  its  course,  the 
nerve  is  separated  from  the  mucous  membrane  by  only  a  thin 
plate  of  bone,  which  may  even  be  deficient  in  many  places. 
Indeed,  swelling  of  this  nerve,  causing  temporal  facial  paraly- 
sis, or  destruction  of  it,  producing  permanent  paralysis,  is 
not  uncommon  in  connection  with  a  suppuration  in  the 
middle  ear. 


200  OSSICULA  AUDITUS. 

OSSICULA  AUDITUS. 

3.  The  three  small  bones  of  the  ear,  the  ossicula  auditus, 
which  serve  for  the  conduction  of  the  sonorous  undulations 
through  the  tympanum  to  the  labyrinth,  are  the  malleus,  or 
hammer ;  the  incus,  or  anvil ;  and  the  stapes,  or  stirrup. 

Fig.  46. 


The  rnalhus  may  be  described  as  consisting  of  the  head, 
neck,  short  process,  manubrium  or  handle,  and  the  long  pro- 
cess or  processus  gracilis.*  The  head  is  the  larger,  upper 
extremity  of  the  bone.  Posteriorly  it  has  an  elliptical  de- 
pression, twice  or  thrice  as  long  as  it  is  broad,  and  of  con- 
siderable depth  for  articulation  with  the  incus.  Below  the 
head  is  a  constricted  portion  called  the  neck,  and  just  below 
this,  and  on  the  upper  end  of  the  manubrium,  is  a  promi- 
nence to  which  the  processes  are  attached.  The  manu- 
brium extends  downward  and  inward,  being  inserted  into  the 
drum-membrane  between  the  circular  and  radiating  fibres  of 
the  middle  layer.  The  processus  gracilis  passes  from  the 
eminence  below  the  neck  forward  and  outward  to  the  Glaserian 
fissure.  The  short  process  lies  at  the  base  of  the  manubrium 
opposite,  where  it  gives  attachment  to  the  tensor  tympani. 

The  incus  lies  just  back  of  the  malleus,  and  may  be  de- 
scribed as  having  a  body  and  two  processes,  On  the  anterior 
and  inner  surface  of  the  head  is  seen  the  surface  for  articula- 
tion with  the  malleus.  The  short  process  projects  backward 
and  articulates  with  the  posterior  wall  of  the  tympanum. 
The  long  process,  much  more  slender  than  the  other,  descends 
at  a  right  angle  with  the  short  process,  and  parallel  with  and 
behind  the  manubrium,  to  end  in  the  processus  lenticularis  which 
articulates  with  the  head  of  the  stapes.  This  articulation  lies 
a  little  higher  than  the  tip  of  the  manubrium. 

The  stapes  consists  of  the  head,  neck,  crura  and  base,  and 

*  Some  writers  call  the  handle  of  the  malleus  the  long  process. 


OSSICULA.  AUDITUS. 


201 


is  tlie  innermost  and  smallest  of  the  bones  of  the  ear,  and 
indeed  of  the  body.  The  head  presents  on  its  outer  part  a 
surface  for  articulation  with  the  lenticular  process  of  the  long 
process  of  the  incus.  Just  internally  to  the  head  is  the  con- 
stricted portion  called  the  neck,  into  which  is  inserted  the 
stapedius  muscle.  From  the  neck  the  crura  diverge  horizon- 
tally, the  one  forward  and  inward,  the  other  backward  and 

Fig.  47. 


The  OssicuZa  Auditus  of  the  Left  Cavity  of  the  Tympanum,  seen  from  within. 
1.  The  malleus,  with  the  handle  running  downwards,  and  the  processus  gracilis  running  to  the 
right.    2.  The  incus,  with  its  short  process  running  to  the  left,  and  its  long  process  in 
articulation  with  the  stapes.    3.  The  stapes. 

The  Ossicula  Auditus  of  the  Bight  Cavity  of  the  Tympanum,  seen  from  within. 
1.  Tlie  head  of  the  malleus.    2.  The  processus  gracilis.    3.  The  long  process,  or  handle.    4. 
Long  process  of  the  incus.    5.  The  short  process  of  the  incus.    6.  The  stapes. 

Tlie  Bight  Annulus  Tympanicus,  or  Long  Bing,  of  the  Newly  Born,  seen  from  without. 
1.  The  anterior  thicker  part,  in  the  newly  bom,  lies  next  to  the  Claserian  fissure,  which  is 
quite  wide,  and  just  behind  the  condyloid  fossa  unites  with  the  squamous  portion  of  the 
temporal  bone.  2.  A  process  on  the  posterior  half  of  the  ring,  about  the  middle,  which  is 
always  present  in  varying  degrees  of  development.— (From  Budinger's  Photographic 
Atlas  des  Menschlichen  Gehororganes.) 

inward,  to  be  inserted  into  a  thin  plate  constituting  the  base, 
which  lies  upon  the  membrana  tympani  secundaria.  On  the 
outer  side  of  the  base  is  a  delicate  ridge  running  from  the 
extremities  of  the  crura  and  into  which  is  inserted  the  abtu- 
rator  stapedis. 

4.  Of  the  ligaments  of  tlie  ossicles  we  have  two  classes  :  the 
ligaments  of  the  movable  joints  and  those  of  the  immovable 
joints. 

The  maUeo-incus  joint  may  be  classed  with  the  gynglimus 


202  OSSICUIA  AUDITUS. 

articulations  on  account  of  the  character  of  the  articulating 
surfaces.  These  surfaces  are  covered  by  cartilage  about 
0.04rain.  in  thickness.  The  capsule  is  tense.  This  joint  is 
provided  with  synovial  membrane. 

The  articulation  between  the  short  process  of  the  incus 
and  the  posterior  tympanic  wall  is  an  amphiarthrosis,  and  is 
surrounded  by  a  tolerably  thick  and  tense  capsule.  The  mo- 
tion is  quite  restricted. 

The  joint  between  the  processus  lenticularis  of  the  incus 
and  the  head  of  the  stapes  is  an  arthrosis,  the  processus  len- 
ticularis corresponding  to  the  ball  and  the  head  of  the  stapes 
to  the  socket.  Both  surfaces  are  covered  with  cartilage. 
The  cartilage  is  much  more  delicate  than  those  of  the  other 
joints,  and  is  characterized  by  being  rich  in  elastic  fibres. 

The  lig amentum  obturatorium  stapedis  is  a  thin  membrane 
inserted  into  the  ridge  on  the  outer  side  of  the  base  of  the 
stapes  and  into  the  inner  edges  of  the  crura,  closing  the  open- 
ing formed  by  these  parts. 

The  head  of  the  malleus  lies  sometimes  in  contact  with  the 
roof  of  the  tympanic  cavity.  More  frequently  it  is  connected 
with  the  roof  by  the  cylindrical  lig.  mallei  superius  (Soemmering). 
The  neck  of  the  malleus  is  held  in  place  by  the  cartilage  which 
sometimes  takes  the  place  of  the  long  process,  and  by  the 
lig.  mallei  anterius  (Arnold),  which  goes  from  the  spina  angularis 
of  the  sphenoid  parallel  with  the  fissura  petro-tympanica  to 
be  inserted  upon  the  head  of  the  malleus. 

The  incus,  when  not  in  immediate  'contact  with  the  roof  of 
the  tympanum,  is  attached  to  the  roof  by  means  of  the  lig. 
incudis  superius  (Arnold),  and  is  inserted  into  the  posterior 
border  of  the  body  of  the  bone. 

5.  The  tensor  tympani  muscle  arises  in  front  of  the  anterior 
opening  of  the  canalis  musculo-tubarius  from  the  pyramid  of 
the  temporal  bone,  from  the  upper  wall  of  the  tubal  cartilage 
and  from  the  neighboring  border  of  the  sphenoid.  It  passes 
over  the  septum  tubas  into  and  through  the  canal  of  the  tensor 
tympani.  Just  before  leaving  the  canal  it  becomes  tendinous. 
The  tendon  at  the  extremity  of  the  canal  turns  outward  and 
runs  nearly  at  a  right  angle  with  the  muscular  part  to  the 
base  of  the  manubrium  mallei. 


BLOOD-VESSELS   OF  THE  TYMPANUM.  203 

The  stapedius  muscle  arises  from  the  bottom  of  the  pyra- 
mid, or  eminerjtia  stapedii,  the  hollow  of  which  it  fills.  At  the 
orifice  of  the  canal  it  becomes  tendinous,  and  thence  runs,  at 
an  obtuse  angle  with  the  rest  of  the  muscle,  to  the  head  of  the 
stapes.  This  is  the  smallest  distinct  muscle  of  the  human 
body. 

6.  The  mucous  membrane  of  the  tympanum  is  a  continuation 
of  that  of  the  Eustachian  tube  and  naso-pharyngeal  space. 
It  is  extremely  delicate  and  consists  chiefly  of  an  epithelium 
and  a  layer  of  connective  tissue  underneath.  On  the  lower, 
the  anterior  portion  of  the  inner,  and  the  posterior  walls,  the 
epithelium  consists  mainly  of  columnar  cells ;  while  on  the 
promontory,  roof,  membrana  tympani  and  ossicles,  pavement 
cells  predominate.  The  thinness  of  the  connective  tissue  is  such 
that  Yon  Troltsch  asserts  that  the  mucous  membrane  cannot 
be  separated  from  the  periosteum,  and  that  every  catarrh  is 
a  periostitis.  But,  according  to  Kessel,  the  connective  tissue 
of  the  mucous  membrane  in  some  places  forms  a  fibrous 
frame-work  which  separates  from  the  periosteum,  and  passes 
from  one  projection  of  bone  to  another  through  the  free  space 
of  the  cavity.  One  such  bridge  has  frequently  been  observed 
to  pass  from  the  eminentia  pyramidalis  to  the  processus 
cochleariformis,  while  many  are  seen  on  the  floor  of  the 
tympanum. 

BLOOD-VESSELS. 

The  tympanum  receives  its  nutrition  from  five  sources  : 

1.  The  tympanic  branch  of  the  internal  maxillary  which 
supplies  the  membrana  tympani. 

2.  The  stylo-mastoid  branch  of  the  posterior  auricular 
which  supplies  the  back  part  of  the  tympanum  and  mastoid 
cells. 

3.  The  petrosal  branch  of  the  middle  meningeal  and 
branches  of  the  ascending  pharyngeal  and  internal  carotid. 

The  veins  of  the  tympanum  empty  into  the  middle  menin- 
geal and  pharyngeal. 

NERVES. 

The  tensor  tympani  muscle  is  supplied  by  a  branch  from 


204:  NERVES  OF  THE  TYMPANUM. 

the  otic  ganglion,  and  from  the  internal  pterygoid,  a  branch  of 
the  third  division  of  the  trifacial. 

The  stapedius  is  supplied  by  a  filament  from  the  facial 
nerve. 

The  nerves  of  the  mucous  membrane  are  derived  from  the 
tympanic  plexus,  consisting  of  a  combination  of  the  great  sym- 
pathetic, the  trifacial,  and  the  glossopharyngeal. 

The  nerves  that  make  up  the  tympanic  plexus,  according 
to  Von  Troltsch,*  are 

1.  Several  carotico-tympanic  nerves,  branches  from  the 
plexus  of  the  sympathetic  in  the  carotid  canal,  which  enter 
the  cavity  of  the  tympanum  through  special  foramina. 

2.  A  twig  of  the  superficial  petrosal  nerve,  entering  the 
cavity  from  above.  It  is  regarded  by  some  as  a  connection 
between  the  otic  ganglion  and  bend  of  the  facial.  Others 
consider  it  a  continuation  of  the  tympanic  nerve  (Jacobson's) 
to  the  otic  ganglion. 

3.  The  ramifications  of  the  tympanic  nerve,  arising  from 
the  glosso-pharyngeus. 

The  otic  ganglion  is  situated  near  the  foramen  ovale  of  the 
greater  wing  of  the  sphenoid  bone,  in  front  of  the  middle 
meningeal  artery,  on  the  outer  side  of  the  cartilage  of  the 
Eustachian  tube,  and  the  point  of  origin  of  the  tensor  tympani 
muscle. 

It  is  made  up  of  motor  fibres  from  the  third  division  of  the 
fifth  nerve,  of  sensory  fibres  from  the  glosso-pharyngeal,  and 
of  fibres  from  the  great  sympathetic. 

Its  branches  of  distribution  are  to  the  tensor  tympani  and 
the  tensor  palate  muscles.  It  sends  a  twig  to  the  external 
pterygoid  branch  of  the  fifth  nerve,  and  several  communicating 
branches  to  the  auricular  nerve  of  the  third  branch  of  the  fifth 
nerve. 

By  this  ganglion  the  soft  palate,  the  drum-head  and  tensor 
tympani,  and  the  integument  of  the  external  ear  are  put  in 
relation  with  each  other  and  with  the  general  nervous  system. 
—{Von  Troltsch) 

The  chorda  tympani  nerve  seems  to  pass  through  the  tym- 

*  Treatise  on  the  Ear,  American  translation,  p.  97. 


MASTOID  PROCESS.  205 

panic  cavity  without  being  in  any  physiological  relation  to  it. 
Division  of  this  nerve  in  operations  upon  the  tensor  tympani 
muscle  usually  has  no  effect  upon  the  functions  of  the  ear.* 


THE  MASTOID  PROCESS. 

The  mastoid  portion  of  the  temporal  bone  ({laorog,  a  nipple 
or  teat)  is  situated  at  the  posterior  part  of  the  temporal  bone. 
Its  external  surface  is  rough,  and  perforated  by  numerous 
foramina.  One  of  these,  of  large  size,  situated  at  the  poste- 
rior border  of  the  bone,  is  called  the  mastoid  foramen. 
Through  it  passes  a  vein  to  the  transverse  sinus  and  a  small 
artery. 

This  roughened  appearance  of  the  mastoid  is  sometimes 
so  marked  that  it  resembles  the  inner  cellular  structure  of  the 
bone.  In  some  rare  cases  there  is  even  complete  absence  of 
the  outer  layer  of  bone,  so  that  the  air  cavities  open  exter- 
nally, as  well  as  into  the  cavity  of  the  tympanum  and  the 
external  auditory  canal. 

Gruber  t  has  seen  emphysema  of  the  neck  and  of  the  occi- 
pital region  result  from  the  inflation  of  the  cavity  of  the  tym- 
panum in  cases  where  such  external  openings  existed  under 
the  skin. 

This  foramen  does  not  always  exist  in  the  mastoid  process, 
but  is  sometimes  found  in  the  occipital  bone,  or  in  the  suture 
between  the  temporal  and  the  occipital. 

The  mastoid  portion  is  continued  below  into  a  conical  pro- 
jection, which  is  the  true  mastoid  process.  To  this  process 
are  attached  the  sterno-mastoid,  the  splenius  capitis,  and 
trachelo-mastoid  muscles. 

On  the  inner  side  of  the  mastoid  process  is  a  deep  groove, 
called  the  fossa  sigmoidea  (see  cut  on  page  197).  In  this 
groove  is  a  part  of  the  lateral  sinus,  and  the  mastoid  foramen 
opens  into  it.  The  mastoid  process  is  hollowed  out  into  a 
number  of  spaces  of  various  size,  which  are  called  the  mastoid 
cells. 

*  See  Chapter  X.  for  an  account  of  the  functions  of  the  chorda  tympani. 
\  Lehrbuch,  p.  32. 


206  THE   MASTOID  CELLS. 


THE  MASTOID  CELLS. 


The  upper  or  horizontal  part  of  the  process,  called  also  the 
antrum  mastoideum,  is  in  communication  with  the  tympanum 
by  means  of  one  or  more  openings  in  the  posterior  tympanic 
wall ;  and  since  it  exists  even  in  the  infant,  before  the  develop- 
ment of  the  mastoid  process,  it  has  been  suggested  that  the 
name  of  "upper  cavity  of  the  tympanum"  would  be  more 
appropriate.  The  second  part  of  these  cells,  lying  in  the  mas- 
toid process  of  the  temporal  bone,  are  below  the  horizontal 
part.  The  whole  consist  of  a  great  number  of  irregular  spaces 
of  varying  sizes — sizes  that  also  vary  much  in  different  indivi- 
duals. The  whole  are  enclosed  by  a  dense  cortical  layer  of 
bone,  separating  them  from  the  cavity  of  the  skull,  and  limit- 
ing them  externally.  This  cortical  layer  also  is  of  different 
thicknesses  in  different  individuals,  a  fact  of  some  practical 
importance  in  cases  of  suppurative  inflammation  of  the  mid- 
dle ear  implicating  these  cells.  Several  small  foramina  are 
seen  in  the  mastoid  portion  of  the  temporal  bone — openings 
for  branches  of  the  middle  meningeal  artery  and  the  vasa 
emissaria  Santorini. 

The  cells  are  lined  by  a  mucous  membrane  similar  to  that 
of  the  membrana  tympani,  but  it  is  more  delicate. 

The  epithelium  consists  of  smooth  cells  of  the  same  con- 
sistency and  arrangement  as  those  of  the  membrana  tympani. 
Under  this  we  find  two  layers  of  connective  tissue,  correspond- 
ing to  the  periosteum.  The  latter  layer  contains  numerous 
nerves,  and  blood  and  lymph  vessels.  The  upper  layer  very 
frequently  separates  itself  at  the  free  edge  of  the  cells,  like  a 
membrane,  and  becomes  attached  to  more  closely  lying  tips 
or  projections  of  bone.  By  this  means  the  cavities  of  two 
cells  lying  next  each  other  become  separated.  In  the  larger 
cells  these  membranes  are  stretched  horizontally,  like  cur- 
tains, by  means  of  processes  which  arise  from  them. — 
(Kessd.)* 

At  birth  the  mastoid  process  is  but  the  rudiment  of  what  it 
is  afterwards  to  be.     It  is  a  small  tuberosity,  and  contains  but 

*  Handbuch  der  Lebre  von  den  Geweben.    Vierte  Lieferung,  p.  864 


THE  MASTOID    CELLS.  207 

one  cell  of  any  considerable  size,  which  afterwards  becomes 
the  mastoid  antrum. 

Dr.  Giovanni  Zoja,*  of  Pavia,  examined  sixty-eight  fresh 
preparations,  and  one  hundred  dry  ones,  in  order  to  get  the 
average  size  of  the  mastoid  process  and  its  cavities.  The 
result  of  his  investigations  is,  that  the  breadth  of  the  mastoid 
is  19  millimetres,  its  thickness  13mm.,  and  its  length  12mm. 
About  one  millimetre  should  be  deducted  from  these  measure- 
ments in  the  bone  of  the  female  subject.  Zoja  does  not  con- 
firm Velpeau's  view,  that  the  mastoid  process  is  more  devel- 
oped in  advanced  life.  The  cortical  layer,  according  to  these 
examinations,  has  an  average  thickness  of  from  one  to  two 
millimetres. 

In  two  of  the  sixty-eight  specimens  belonging  to  one  subject 
the  cells  were  united  into  one  large  cavity,  so  that  they  formed, 
as  it  were,  a  mastoid  cavity.  This  was  also  found  in  another 
case  on  one  side  only.  The  cells  in  the  centre  of  the  process  are 
usually  the  larger,  and  communicate  with  one  another,  if  they 
are  not  separated  by  the  membane  that  has  been  described. 
In  several  cases  there  were  cells  only  in  the  base  of  the  process. 
Occasionally  these  cells  extended  to  the  side  of  the  skull,  or 
even  to  the  middle  of  the  petrous  part  of  the  temporal  bone. 

Dr.  Zoja  thinks  that  the  development  of  the  cellular  struc- 
ture goes  on  in  a  kind  of  system.  They  become  gradually 
larger,  they  are  lined  with  a  peculiar  membrane,  in  the  spaces 
a  gelatinous  mass  is  found,  which  becomes  gradually  serous, 
and  is  either  taken  up  by  the  vessels  of  the  cavities  or  passes 
into  the  cavity  of  the  tympanum,  where  it  is  absorbed. 

In  five  of  the  sixty-eight  specimens  the  antrum  was  found 
to  be  separated  from  the  other  cellular  spaces  by  a  membran- 
ous partition,  f 

BLOOD-VESSELS  OF  THE  MASTOID  PEOCESS. 

The  blood  supply  of  the  mastoid  cells  is  furnished  by  the 
stylo-mastoid  branch  of  the  posterior  auricular  artery,  while 
their  nerves  come  from  the  tympanic  plexus. 

*  Gruber's  Lahrbuch,  p.  33. 
t  Henle,  Lehrbuch,  p.  751. 


208 


EUSTACHIAN  TUBE. 


THE  EUSTACHIAN  TUBE. 


The  Eustachian  tube,  like  the  external  auditory  meatus, 
consists  of  an  osseous  and  a  cartilaginous  part.     The  former 


Fig.  48. 


Section  of  the  Head,  showing  the  Divisions  of  the  Ear  and  the  Naso-pharyngeal  Cavity. 
After  a  Photograph— Eudinger. 

I  Cartilage  of  external  auditory  canal.  2.  Osseous  audUory  canal.  3,  4,  Membranm  Tym- 
vanorum  5.  Cavity  of 'the  tympanum.  6.  Dilator  muscle  of  the  Eustachian  tube.  7. 
Levator  palati  muscle.  8.  Mucous  membrane  of  the  pharyngeal  orifice  of  the  tube.  9. 
Leftmembranatympani.  10.  Handle  of  the  malleus  and  short  process.  11.  Tensor  tym- 
vani  muscle.  12.  Mucous  membrane  of  the  membranous  portion  of  the  tube,  perforated  by 
a  needle  13  Levator  veli  palati  muscle.  14.  Mucous  membrane  of  the  posterior  sur- 
face of  the  pharynx.  15.  Mucous  membrane  of  the  pharynx,  attached  to  the  lower  surface 
.  of  the  body  of  the  sphenoid  bone.  16.  Sphenoidal  sinus.  IT  Hypophysis  cerebri  and  its 
relations  to  the  cerebral  arteries  and  the  cavernous  sinus. 


EUSTACHIAN  TUBE. 


209 


measures  11mm.,  the  latter  24mm.,  so  that  the  whole  length 
of  the  tube,  from  its  opening  into  the  tympanic  cavity  to  its 
pharyngeal  orifice,  measures  35mm.  The  tube,  from  its  tym- 
panic end,  runs  forward,  inward,  and  downward.  Its  axis 
makes  an  angle  of  135°  with  the  axis  of  the  external  auditory 
canal,  and  an  angle  of  40°  with  the  horizontal  plane. 

The  diameter  of  the  osseous  portion  of  the  tube  is  about 
2mm.  The  walls  are  smooth,  and  covered  by  a  mucous  mem- 
brane, which,  like  that  of  the  tympanum,  is  closely  adherent 
to  the  periosteum.  The  lateral  wall  belongs  to  the  pars  tym- 
panica ;  the  median  wall  separates  the  tube  from  the  carotid 
canal ;  the  upper  wall  is  formed  by  the  septum  tubse,  the  floor 
of  the  canal  for  the  tensor  tympani  muscle. 


Fib.  40. 


Transverse  Section  of  the  Upper  Part  of  the  Eustachian  Tube.    After  Henle. 
*  Fibres  of  the  spheno-staphylinus  muscle. 


The  shape  of  the  anterior  extremity  of  the  osseous  tube  is 
very  irregular,  the  inner  wall  extending  forward  much  further 
than  the  lateral  wall.  This  part,  "  the  isthmus,"  is  the 
narrowest  portion  of  the  tube.  Here  the  tube  gradually 
widens,  and  ends  anteriorly  in  a  trumpet-shaped  orifice  9mm. 
high  and  5mm.  broad,  which  projects  slightly  into  the  post- 
14 


210 


EUSTACHIAN  TUBE. 


nasal  space,  and  lies  a  little  above  the  level  of  the  floor  of  the 
nostril. 

The  cartilage  of  the  tube  is  made  up  of  two  plates — a  me- 
dian and  a  lateral.  The  median  plate,  which  is  much  the 
larger,  is  triangular,  and  into  its  upper  and  outer  part  is 
inserted  the  hook-shaped  and  smaller  lateral  cartilage.  But 
most  of  the  lateral  wall  and  all  of  the  lower  is  formed  of 
membrane  instead  of  cartilage,  the  membrane  forming  nearly 
a  half  of  the  circumference  of  the  tube. 


Fig.  50. 


Fig.  51. 


j5"* 


** 


Transverse  Section  through  the  Lower  End  of 
the  Eustachian  Tube.    After  Henle. 

*  Mucous  glands.     *  *  Fibres  of  petrostaphyli- 
nus  muscle. 


Transverse  Section  through  the  Loioer 
End  of  the  Eustachian  Tube.  After 
Henle. 

*  Mucous  glands.  **  Transverse  sec- 
tion of  the  petrostaphylinus  muscle. 


The  median  wall  of  the  cartilage  of  the  tube  is  below  1mm. 
in  thickness  on  its  posterior  extremity,  but  increases  in  size 
gradually  to  2|  to  3m.,  and  on  its  free  anterior  border  may 
even  reach  7mm.  The  tissue  of  the  cartilage  is  chiefly  hya- 
line, but  it  has  a  fibrous  base  substance  at  various  spots; 
sometimes  on  the  surface,  sometimes  on  the  interior,  and 
especially  near  the  edges. 

The  mucous  membrane  which  fills  up  the  concavity  of  the 
cartilage,  and  which  changes  the  caliber  up  to  the  vicinity  of 
the  pharyngeal  orifice  to  a  plane  surface,  is  0.6mm.  thick  at 
its  densest  portion.  It  is  connected  to  the  perichondrium  by 
loose  connective  tissue.  It  is  made  smooth  by  numerous  aci- 
nose glands  of  about  0.6mm.  in  diameter   and  0.15mm.  in 


EUSTACHIAN  TUBE. 


211 


thickness.  These  glands  form  a  continuous  layer  backwards 
from  the  pharyngeal  orifice  for  some  distance.  Towards  the 
cavity  of  the  tympanum  they  are  less  numerous,  yet,  accord- 
ing to  Yon  Troltsch,  they  are  found  on  the  tympanic  orifice. 
Towards  the  pharyngeal  orifice  large  mucous  glands  appear 
lying  on  the  outer  side  of  the  cartilage. 


Lateral  Wall  of  the  Nasal  Cavities,  shmving  the  Phalangeal  Orifice  of  the  Eustachian  Tube. 
After  Henle.     The  Ili.ddle  Turbinated  Bone  is  removed. 

Mm.  Border  of  attachment  of  the  middle  turbinated  bone.  The  upper  membrane  is  sjMt  by  a 
vertical  section,  and  turned  back  on  two  sides,  in  order  to  show  the  openings  of  the  upper 
ethmoidal  cells.  V..S.  Frontal  sinus.  S.  S.  Sphenoidal  sinus.  1.  Openings  of  the  lower 
ethmoidal  cells.  2.  Probe  entering  into  themiddle  nasal  space  from  the  frontal  sinus.  S. 
Constant  opening  between  the  antrum  of  the  lower  jaw  and  the  nasal  cavity.  4.  Occa- 
sional opening  between  the  same  parts.    5.  Pharyngeal  orifice  of  the  Eustachian  tube. 

The  lateral  wall  of  the  tube,  which,  with  its  upper  border, 
bounds  the  convex  surface  of  the  enveloping  ridge  of  the  car- 


212 


EUSTACHIAN  TUBE. 


tilage,  has  about  the  same  thickness  as  the  median  wall,  and 
the  same  covering  of  mucous  membrane.  The  tissue  in  the 
upper  half  is  quite  firm,  in  the  lower  more  relaxed  and  spongy. 
Fat  is  its  chief  structure. 

A  portion  of  the  tendinous  origin  of  the  spheno-staphyli- 
nus  muscle  unites  with  the  firmer  portion  of  the  wall,  and  for 
some  distance  this  origin  runs  in  a  thin  layer  between  the 
upper  border  of  the  soft  wall  of  the  tube,  and  unites  with  the 
convex  surface  of  the  latter. 

rig.  53. 


Transverse  Section  of  Eustachian  Tube  and  Surrounding  Parts.    After  BUdinger. 
1.  Median  cartilaginous  plate.    2.  Lateral  cartilaginous  hook.    3.  Dilator  of  the  tube.    4.  Lo> 
vator  of  the  soft  palate.    5.  Basilar  fibro-car  tilage.    6  and  7.  Acinous  glands.    8.  Fat  in 
the  lateral  watt.    9.  Safety  tube.    10.  Accessory  fissure.    11.  Fold  of  mucous  membrane. 
12.  Adjacent  tissues. 

The  spheno-staphylinus  muscle  being  thus  attached  to  the 
tube  has  the  power  of  rolling  over  the  upper  inverted  border 
of  the  cartilage,  and  of  enlarging  the  angle  which  the  lateral 
wall  forms  with  the  median. 

The  opening  or  gaping  of  the  tube  depends  upon  this 
action,  which  occurs  with  the  act  of  swallowing. 


EUSTACHIAN  TUBE.  213 

At  the  point  where  the  lateral  wall  of  the  nasal  cavity 
passes  into  the  pharynx,  at  the  same  height  with  the  posterior 
point  of  the  inferior  turbinated  bone,  lies  the  pharyngeal  ori- 
fice of  the  tube.,    (Fig.  52.) 

Since  the  inner  wall  of  this  canal  projects  into  the  caliber 
of  the  naso-pharyngeal  space,  the  mouth  of  the  tube  lies  more 
in  a  frontal  than  sagittal  plane.  It  has  a  puny  median  border, 
while  the  lateral  wall  passes  without  any  distinct  line  of  sep- 
aration into  the  nasal  cavity.  The  width  of  the  mouth  of  the 
tube  varies  in  different  persons,  and  has  the  general  shape  of 
a  funnel. 

According  to  Rudinger,*  the  minute  differences  in  form  of 
the  Eustachian  tube  in  animals  is  so  characteristic,  that  from 
a  section  of  the  Eustachian  tube,  the  animal  from  which  it  has 
been  taken  can  be  designated. 

The  known  functions  are  to  conduct  away  the  secretions 
of  the  cavity  of  the  tympanum,  and  to  act  as  a  ventilator  of 
this  part.  What  part  it  has  to  do  with  the  conduction  of 
sound  to  the  ear,  or  what  connection  it  has  with  the  voice,  has 
not  as  yet  been  determined.  Rudinger  has  observed  fatty 
degeneration  of  the  tubal  cartilage  of  man,  and  it  may  be 
conceived  that  fatty  degeneration  of  its  muscles  may  occur 
in  some  subjects  and  become  a  serious  impediment  to  the  per- 
formance of  its  functions. 

The  mucous  membrane  of  the  tube  is  at  its  lower  part 
quite  thick,  like  that  of  the  pharynx,  of  which  it  is  an  imme- 
diate continuation.  Its  epithelium  is  ciliated,  the  motion 
being  in  the  direction  of  the  pharynx.  This  anatomical  fact 
explains  the  intolerance  which  this  membrane  displays  towards 
the  injection  of  fluids  from  the  pharyngeal  orifice.  The  tube 
of  the  infant  differs  much  from  that  of  the  adult.  It  is  shorter, 
wider,  and  more  nearly  horizontal. 

Rudinger  divides  the  fissure  of  the  tube  into  two  portions. 
There  is  a  semi-cylindrical  space  under  the  hook  of  the  carti- 
lage which  he  calls  the  safety  tube,  and  the  fissure  connecting 
with  it  the  accessory  fissure. 

Both  divisions  are  produced  by  the  shape  of  the  cartilage, 

*  Strieker's  Hand-book,  p.  973. 


214  EUSTACHIAN  TUBE. 

and  are  separated  from  each  other  by  projections  of  mucous 
membrane.  The  mucous  membrane  is  firmly  attached  to  the 
tissues  about  it  on  the  concavity  of  the  hook  ;  but  at  that  point 
where  the  accessory  fissures  begin,  fold-like  projections  are 
produced  between  this  fissure  and  the  safety  tube.  The  pro- 
jection of  these  folds  prevents  the  safety  tube  from  being  closed. 
The  closure  is  first  possible  at  the  point  where  the  bend  of 
the  cartilage  becomes  narrower,  and  the  mucous  membrane  is 
not  closely  united  with  it.  This  point  is  at  about  the  middle 
of  the  tube,  where  the  mucous  membrane  has  a  slightly  undu- 
lating surface,  as  seen  in  Fig.  55. 

The  question  whether  the  tube  is  normally  open — that  is, 
when  the  muscles  of  deglutition  are  at  rest — is  one  which  has 
been  much  debated.  Throughout  the  narrowest  part  of  the 
tube  the  larger  part  of  the  outer  and  inner  walls  are  in  con- 
tact, but  at  the  upper  part  is  a  small  chink  which,  as  some 
authors  claim,  remains  patent,  while  others  deny  this.  How- 
ever, any  observer  with  normal  tubes  will  be  able  to  notice 
that  the  tube  opens,  or  at  least  widens,  at  every  act  of  swal- 
lowing. If  the  nostrils  are  tightly  held,  air  will  be  pumped 
out  of  the  tympanum  by  the  act  of  swallowing,  and  this  air 
will  be  restored  again  to  the  ear-drum  by  swallowing  with  the 
nostrils  free. 

MUSCLES  OF  THE  TUBE. 

The  muscular  apparatus  of  the  Eustachian  tube  also  be- 
longs to  the  pharynx.  Indeed,  these  parts  are  so  closely  con- 
nected in  all  their  structures,  that  an  affection  of  one  part 
independent  of  the  other,  can  hardly  be  said  to  occur. 

The  muscles  of  the  tube  are 

1.  The  Abductor  or  Dilator  of  the  Tube. — This  muscle  is 
also  known  as  the  spheno-salpingo  staphylinus  muscle,  the 
circumflexus  palati,  or  tensor  palati  mollis.  It  is  probably  the 
most  important  muscle  of  the  tube. 

This  muscle  arises  from  the  sphenoid  bone  and  the  carti- 
lage of  the  tube.  It  is  inserted  on  the  blunt  edge  of  the  car- 
tilaginous plate  along  the  whole  length  of  the  canal.  It  passes 
forward,  inward,  and  downward,  and  its   fibres   spread  out 


EUSTACHIAN   TUBE.  215 

along  the  edge  of  the  soft  palate,  and  on  the  side  of  the  pha- 
rynx. It  enlarges  the  caliber  of  the  tube  by  drawing  the  hook 
of  the  cartilage  forward  and  a  little  downward. 

Kudinger  confirms  the  view  expressed  by  Yon  Troltsch 
and  Mayer  that  the  dilator  of  the  tube  passes  directly  into  the 
tensor  tympani  muscle.  This  is  true  not  only  of  the  tendons, 
but  also  of  the  muscular  fibres. 

Fig.  54. 


Section  of  the  Upper  Third  of  the  Eustachian  Tube.    After  Budinger. 

1.  Median  cartilage.  2.  Lateral  cartilage  hook.  3.  Perichondrium.  4.  Submucosa.  5.  Inser- 
tion of  the  dilator  of  the  tube.  6.  Safety  tube.  7.  Lateral  projection  of  the  mucous  mem- 
brane.   8.  Median  projection  of  the  mucous  memb?'ane.    9.  Accessory  fissure. 

Rudmger  compares  the  rolling  of  the  muscle  about  the 
hamular  process  of  the  pterygoid  plate  of  the  sphenoid  to  the 
pulley  arrangement  of  the  superior  oblique  muscle  of  the  eye. 
This  attachment  is  certainly  a  point  of  fixation  in  the  move- 
ments of  the  muscle. 

2.  The   Levator    Veli  Palati. — This  muscle  is  not  very  inti- 


216 


EUSTACHIAN  TUBE. 


mately  connected  with  the  tube,  and  yet  it  plays  an  important 
part  in  its  mechanism.  It  arises  with  a  cylindrical  tendon  on 
the  lower  surface  of  the  temporal  bone,  on  the  anterior  border 
of  the  entrance  to  the  carotid  canal,  and  by  a  few  fibres  from 
the  cartilaginous  portion  of  the  tube. 

In  the  soft  palate  the  muscles  of  the  two  sides  are  closely 
connected.  From  this  point  they  separate,  and  each  one  runs 
upward,  and  is  firmly  attached,  in  the  vicinity  of  the  osseous 
tube,  not  only  on  the  bone,  but  also  to  the  cartilage  and  the 
mucous  membrane  of  the  tube. 


Fig.  55. 


Section  of  the  Mddle  Third  of  the  Eustachian  Tube.    After  Biidinger. 

1,  2.  Cartilage.    3.  Dilator  of  the  Tube.    4.  Folds  of  mucous  membrane  under  the  cartilage 
hook.    5.  Folds  of  mucous  membrane  in  the  accessory  fissure.   6.  Submucosa. 


When  this  muscle  contracts,  by  its  becoming  thicker,  the 
membranous  floor  of  the  tube  is  pressed  forward,  and  thus  the 
long  diameter  of  the  tube  is  shortened,  and  the  transverse  dia- 
meter is  enlarged,  that  is  to  say,  it  is  made  to  gape  very 


EUSTACHIAN  TUBE.  217 

widely.*    The  salpingo-pharyngeus  muscle  also  assists  in  this 
action. 

3.  The  Salpingo  -  pharyngeus. — This  is  a  thin  muscular 
layer,  that  ascends  from  the  lower  end  of  the  tube  obliquely 
downwards  and  backwards,  and  is  connected  to  the  lower  end 
of  the  median  cartilaginous  plate,  and  to  the  mucous  mem- 
brane. It  is  inserted  in  the  posterior  wall  of  the  pharynx. 
Riidinger  considers  this  thin  muscle  to  be  a  fixator  of  the 
median  cartilaginous  plate. 

The  opening  of  the  Eustachian  tube  is  the  result  of  a  com- 
bination of  muscular  action.  If  the  three  muscles  are  inner- 
vated simultaneously,  and  their  contractions  occur  at  the 
same  time,  the  hook-shaped  cartilage  is  fixed  by  the  dilator 
of  the  tube  and  drawn  outward,  the  concave  portion  of  the 
tube  becomes  a  little  less  curved,  and  the  semi-cylindrical 
gutter  is  widened.  If  the  levator  of  the  velum  contract,  the 
space  of  the  tube  at  the  pharyngeal  orifice  is  enlarged  more 
than  three  lines. 

If  the  muscles  cease  to  act,  the  elasticity  of  the  cartilage 
comes  into  play,  the  canal  becomes  narrower,  without  being 
at  its  lower  section  completely  closed,  however,  t  Respiratory 
movements  of  the  membrana  tympani  have  been  often  ob- 
served, and  these  occur  through  this  gap  in  the  tube,  which 
cannot  be  said  to  be  ever  firmly  closed.  Any  one  who  has 
often  climbed  high  mountains  and  has  become  "  out  of  breath  " 
from  exertion  in  reaching  the  top,  must  have  observed  in  his 
own  ears  this  continuation  of  respiration  through  the  tube. 
This  fact  throws  light  upon  the  etiology  of  cases  of  diseases  of 
the  middle  ear,  arising  from  inflammations  of  the  respiratory 
organs,  such  as  Pneumonia  and  Bronchitis. 

BLOOD-VESSELS. 

1.  The  ascending  pharyngeal  artery,  from  the  external 
carotid. 

*  Riidinger,  Beitrage  zur  vergleichenden  Anatomie  und  Histologie  der  Ohr- 
trompete. 

f  Riidinger,  1.  c,  p.  7. 


218  EUSTACHIAN  TUBE. 

2.  The  internal  maxillary,  the  larger  of  the  two  terminal 
branches  of  the  external  carotid,  also  supplies  the  Eustachian 
tube  by  its  middle  meningeal  branch. 

3.  Branches  of  the  internal  carotid  artery. 

NERVES. 

1.  The  internal  pterygoid,  a  branch  of  the  third  division 
of  the  fifth  nerve,  sends  a  supply  to  the  dilator  of  the  tube. 

2.  The  superior  pharyngeal,  a  branch  of  the  second  divi- 
sion of  the  fifth  nerve,  sends  branches  to  the  pharyngeal 
orifice. 

3.  The  glosso-pharyngeal  supplies  the  mucous  membrane. 

4.  The  pneumogastric  supplies  the  levator  veli  palati 
muscle. 

Historical. — The  history  of  the  successive  steps  by  which 
the  Eustachian  tube  has  taken  its  true  and  important  position 
with  relation  to  the  study  and  treatment  of  aural  disease  is  a 
very  interesting  one,  and  has  been  very  succinctly  given  by 
Dr.  Ludwig  Mayer,*  from  whose  writings  the  author  has 
already  quoted  in  the  chapter  on  Foreign  Bodies. 

As  has  been  said  on  page  19,  Alcmeon  and  Aristotle  knew 
of  the  Eustachian  tube,  but  Eustachius  was  the  first  writer 
who  gave  an  exact  description  of  it.  This  is  found  in  the 
edition  of  his  anatomical  works  published  in  Yenice  in  1564. 
(Bartliolomaii  Eustacliii  Opuscula  Anatomica.) 

The  passage  in  reference  to  the  tube,  as  quoted  by  Mayer, 
is  as  follows : 

Ergo  a  caverna  ossis  lapidei,  in  quam  meatus  auditorius,  conchion  appella- 
tus  finitur,  via  in  narium  cavitatem  perforata  est :  ab  ilia  enim  meatus  alter 
oritur  rotundo  canaliculo  similis,  et  instar  tenuioris  calami  amplus,  qui  oblique 
ad  interius  interiusque  basis  capitis  latus  procedens,  in  medio  quatuor  forami- 
num,  totum  istud  os  penetrat  atque  perfodit.  nil  posteriori  ipsius  sede  arteria 
sopor  aria  calvaria  ingreditur :  anteriori  quartum  nervorum  cerebri  jugum 
extra  ipsam  emergit :  externum  latus  arteriae  in  dura  cerebri  membrana  dis- 
tributae  aditum  patefacit :  internum  denique  fissura  quaedam  circumscribit, 
quae  a  cuneum  referentis  ac  lapidei  ossis  extremis  partibus,  oblique  infra  et 
anteductis,  fit.     Caeterum  bunc  meatum,  de  quo  sermo  est,  arbitrabitur  for- 

*  Studien  iiber  die  Anatomie  des  Canalis  Eustacbii.    Muncben,  18G6. 


EUSTACHIAN  TUBE.  219 

tasse  qnispiani  eo  loco  desinere  ;  res  autem  non  ita  se  habet,  sed  alterius  gen- 
eris substantia  auctum,  inter  duos  faucium  seu  gulae  musculos,  a  paucis  hucus- 
que  bene  cognitos  secundum,  paulo  ante  me  moratae  fissurae  ductum  ulterius 
procedit ;  et  juxta  radicem  internae  partis  apophysis  ossis  alis  vespertilionum 
similis  in  alteram  narinm  cavitatem  terminatur  ;  et  in  crassam  palati  tunicam 
prope  radicem  gargareonis  inseritur.  Substantia  sane  ej  us,  qua  extrema  fis- 
surae ossi  temporum  et  cuneo  simili  communis  tangit,  cartilaginea  est  ac 
admodum  crassa ;  liuic  vero  appositae  partis  substantia  exacta  cartilago  non 
est,  sed  membranosum  nescio  quid  habet,  et  tenuior  evadit  a  hujus  meatus 
intena  extremitas  narium  cavitatis  medium  respicies  robusta  est  cartilago,  quae 
plurimum  extuberat,  mucosaque ;  narium  tunica  obducitur,  ac  fini  ejusdem 
meatus  quasi  canitor  praeferta  esse  videtur.  figura  teres  non  est,  sed  aliquan- 
tum  depressa  duos  efficit  angulos:  latitudo  cavitatis  calamum,  quo  scribimus, 
fere  adaequat,  sed  in  fine  duplo  latior  est,  quam  in  principio,  quae  similiter 
mucosa  sed  tenui  induitur  tunica.  Hoc  callidissimum  naturae  artificium  a  me 
inventum  contemni  (ut  opinor)  non  debet :  siquidem  turn  philosophis,  turn 
medicis  non  parum  utilitatis  afferre  potest,  nam  antiquiores  philosophi,  quo- 
rum numero,  ut  Aristoteles  refert  primo  de  natura  animalium  undecimo  fuit 
Alcmeon,  capras  non  modo  ore  ac  naribus,  verum  etiam  auribus  quoque  spi- 
rare,  forte  ob  earn  causam  arbitrati  sunt,  quod  meatum  quam  descripsi  non 
ignorarent  atque  adeo  saepius  experti  fuissent  spiritum,  ubi  ipsum  quis  cohi- 
bet,  ad  aurium  cavitatem  vi  quadam  impulsum  recurrere,  et  instar  fiuctus, 
auditus  organa  percutere.  Erit  etiam  medicis  hujus  meatus  cognitip,  ad  rec- 
tum medicamentorum  usum  maxime  utilis,  quod  scient  post  hac  ab  auribus, 
non  augustis  foraminibus,  sed  amplissima  via  posse  materias  etiam  crassas,  vel 
a  natura  expelli,  vel  medicamentorum  ope,  quae  masticatoria  appellantur,  com- 
mode expurgari. 

The  last  paragraph  of  this  quotation  shows,  that  Eusta- 
chius anticipated  an  earlier  use  of  his  discovery  than  "was 
made  by  the  profession. 

The  writers  who  followed  Eustachius  up  to  Valsalva's 
time,  based  their  labors  on  what  Eustachius  had  done.  Mayer, 
in  order  to  express  his  estimate  as  to  their  value,  quotes 
Goethe,  who  says  :  "  Denn  eben  wo  Begriffe  fehlen,  da  stellt 
ein  Wort  zur  rechten  Zeit  sich  ein."  Where  the  ideas  are 
wanting,  words  serve  a  very  good  turn. 

Valsalva,  however,  described  the  muscles  of  the  Eustachian 
tube  very  exactly,  but  a  hundred  and  twenty-five  years  after 
Eustachius.  He  supposed  that  the  function  of  the  muscles 
was  to  keep  the  tube  constantly  open.  It  was  not  until  1850 
that  the  anatomical  descriptions  began  to  be  accurate.  Then 
F.  Arnold,  in  his  Handbuch  der  Anatomie  des  Mensclien,  published 
at  Freiburg  in  Bresgau,  in  1851,  gave  a  careful  description  of 


220  AUTHOEITIES. 

the  tube.  Merkel,  Anatomie  und  Physiologie  der  rnensclilichen 
Stimme  und  des  Sprecli-  Organs,  and  Tortual,  Neuen  Untersuch- 
ungen  iiber  den  Ban  des  menschlichen  Schlundes  und  Kehlhopfes, 
1861,  afterwards  described  the  canal.  Von  Troltsch,*  in  an 
article  published  in  his  Archives,  elaborated  the  subject  much 
farther.  The  labors  of  Mayer  and  Kudinger  have  brought  our 
knowledge  of  the  anatomical  structure  to  the  present  stage. 

It  should  never  be  forgotten  that  Joseph  Toynbee  was  the 
first  writer,  in  a  paper  presented  to  the  Royal  Society  in  1851, 
to  show  that  the  faucial  orifice  was  controlled  by  the  muscles 
of  the  palate,  and  that  the  act  of  swallowing  affected  the 
caliber  of  the  tube.  Toynbee  thought  that  the  tube  was  com- 
pletely closed  in  a  state  of  repose,  and  although  not  strictly 
correct  in  this,  his  labors  can  hardly  be  overestimated. 


AUTHORITIES. 

Soc?idalek,  Prof.  Vierteljakrsschrift  fur  praktische  Heilkunde.  XXIII. 
Jahrgang,  Prag.,  1866,  Bd.  89. 

Gray,  Henry.  Anatomy,  Descriptive  and  Surgical.  Reprint.  Philadelphia, 
1862. 

Gruber,  Josef.    Lehrbuch  der  Okrenheilkunde.    Wien,  1870. 

Gruber,  Josef.  Anatomisch-physiologiscke  Studien  iiber  das  Trommelfell 
und  die  Gekorknockelchen.    Wien,  1867. 

Some,  Everard.    Transactions  of  the  Royal  Society  of  London,  1800,  Part  II. 

JZenle,  J.    Handbuck  der  Eingeweide-lekre.    Braunschweig,  1866. 

Syrtl.  Lehrbuch  der  Anatomie  des  Menscken.  Siebente  Auflage.  Wien, 
1862. 

Jones,  T.  Wharton.  In  tke  Cyclopaedia  of  Anatomy  and  Physiology.  Lon- 
don, 1839.    Vol.  II. 

JCessel,  J~,  Das  mittlere  Ohr.  Handbuch  der  Lehre  von  den  Geweben.  S. 
Strieker,  IV.  Lieferung.     Leipzig,  1870. 

JCessel,  J~.  A  Manual  of  Histology.  By  S.  Strieker  Article,  Outer  and 
Middle  Ear.     Translated  by  J.  Orne  Green.    New  York,  1872. 

Mayer^  Lud  wig.  Studien  iiber  die  Anatomie  des  Canalis  Eustackii.  Miinchen, 
1866. 

*  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  Heft  i.,  p.  15. 


AUTHORITIES.  221 

jpatruban,  Prof.  von.  In  Monatsschrift  fur  Ohrenheilkunde.  Jahrgang  III. 
No.  1. 

'Politzer,  Adam.    Die  Beleuchtungsbilder  des  Trommelfella  im  gcsunden 

und  kranken  Zustande.     Wien,  1865. 
^Politzer,  Adam.     The  Membrana  Tympani  in  Health  and  Disease.     With 

Supplement.      Translated  by  A.  Matkewson,  M.D.,  and  H.  G.  Newton, 

M.D.    New  York,  1869. 

ffiudinger,  JV.    Beitrage  zur  vergleichenden  Anatomie  und  Histologie  der 

Ohrtrompete.     Miinchen,  1870. 
Hudinger,  JV.    Atlas  des  menschlichen  Geho'rorganes,  herausgegeben  von 

Dr.  Riidinger.     Nach  der  Natur  photographirt  von  J.  Albert.     I.— II.  Lie- 

ferung.     Miinchen,  1867. 

'Hudinger,  JV.  In  Strieker's  Manual  of  Histology ;  Article,  The  Eustachian 
Tube.    Translated  by  J.  Orne  Green.    New  York,  1872. 

Shrapnell,  Henry  Jones.  On  the  Form  and  Structure  of  the  Membrana 
Tympani.  The  London  Medical  Gazette,  vol.  x.,  p.  120.  On  the  Func- 
tion of  the  Membrana  Tympani,  ibid.,  p.  282. 

Toynbee,  Joseph.  The  Diseases  of  the  Ear ;  their  Nature,  Diagnosis,  and 
Treatment  (Reprint).    Philadelphia,  1860. 

Yo?i  Troltsch,  Anton.    Archiv  fur  Ohrenheilkunde,  1865. 

yon  Troltsch,  Anton.  The  Diagnosis  and  Treatment  of  Diseases  of  the 
Ear,  including  the  Anatomy  of  the  Organ.  Second  American  edition. 
Translated  by  D.  B.  St.  John  Roosa.    New  York,  1869. 

Yalsalvce  Viri  celeberrimi  Antonii  Marise  opera.  Tractatas  de  Aure  Hu- 
mana.   Lugdunum  Batavorum,  1742. 


CHAPTER    X. 

INJURIES  OF  THE  MEMBRANA  TTMPANI. 

The  diseases  of  the  membrana  tympani  occur  either  as  a 
result  of  an  inflammation  of  the  external  auditory  canal,  or  of 
the  middle  ear.  I  have  not  seen  any  cases  of  independent  or 
primary  myringitis,  or  inflammation  of  the  drum  membrane, 
such  as  are  delineated  with  theoretical  minuteness  by  some 
writers  on  otology.  The  anatomical  structure  of  a  membrane 
that  has  but  one  layer  of  tissue  peculiar  to  itself,  and  that  in 
its  centre,  but  which  is  a  direct  uninterrupted  continuation  of 
the  adjacent  parts,  precludes  the  idea  of  an  inflammation  that 
occurs  primarily  in  this  part.  A  glance  at  the  nerve,  lymph, 
and  blood  supply  of  the  partition  wall  which  is  called  the 
membrana  tympani,  shows  that  it  has  no  independent  nourish- 
ment, and  strengthens  the  view  that  the  inflammations  that 
attack  it,  must  be  of  a  secondary  character.  I  have  therefore 
discarded  the  term  myringitis,  or  inflammation  of  the  drum 
membrane,  except  as  the  name  of  one  of  the  symptoms  of 
otitis  externa  or  media,  or  to  describe  the  inflammation  pro- 
duced by  injury.  There  is  probably  no  independent  disease 
called  myringitis,  in  the  sense  that  we  speak  of  a  keratitis  or  a 
retinitis. 

Dr.  A.  H.  Buck*  has  recently  reported  a  case  of  interlamellar  cyst  of  the 
membrana  tympani,  which  might  be  supposed  to  be  an  independent  disease  of 
this  part ;  but  the  history  shows  that  the  patient  was  suffering,  at  the  time  of 
the  formation  of  the  cyst,  from  chronic  eczema  of  the  auditory  canal,  which 
causes  the  case  to  be  one  of  extension  of  disease  of  the  meatus  to  the  drum- 
head. 

The  membrana  tympani  is,  however,  subject  to  injury  from 
explosions,  or  sudden  and  violent  movements  of  the  atmos- 

*  Medical  Record,  vol.  vii.,  p.  572. 


INJURIES  OP  MEMBRANA  TYMPANI.  223 

phere,  wliich  cause  the  undulations  to  be  condensed  and 
forced  inwards  upon  the  drum-head.  It  may  also  be  ruptured 
by  the  force  of  condensed  air,  as,  for  example,  that  wliich  is 
found  in  passing  through  the  lock  of  a  caisson  used  in  build- 
ing bridges.  The  membrana  tympani  may  also  be  ruptured 
by  blows  upon  the  side  of  the  head  or  upon  the  ear,  or  from 
direct  injury  by  the  striking  of  a  sharp  instrument  directly 
upon  the  membrane,  and  so  forth. 

The  explosion  of  artillery  is  not  apt  to  cause  rupture  of  the 
drum-head.  When  we  consider  the  number  of  persons  who 
have  been  thus  exposed  to  injury,  it  is  somewhat  surprising 
that  no  more  have  suffered  from  this  cause.  After  diligent 
inquiry  among  army  surgeons,  I  have  heard  of  but  very  few 
cases  of  rupture  of  the  membrana  tympani  occurring  from 
this  cause ;  and  although  I  have  seen  many  patients  who 
became  partially  deaf,  from  the  exposures  incident  to  cam- 
paigning, during  our  late  civil  war,  I  have  as  yet  seen  but  one 
case,  where  a  rupture  of  the  drum  membrane  occurred  from 
the  explosion  of  artillery.  The  long-continued  exposure  to 
heavy  firing  often,  and  perhaps  always,  causes  a  temporary 
ringing  in  the  ears,  probably  from  concussion  of  the  laby- 
rinth, and  sometimes  hemorrhage  from  the  vessels  of  the  mem- 
brana tympani,  but  very  rarely  is  a  rupture  produced.  The 
effects  of  the  concussion  do  not  always  pass  away,  and  some 
soldiers  acquire  a  chronic  inflammation  of  the  internal  and  mid- 
dle ears  from  this  cause,  just  as  do  boiler-makers,  who  work 
amid  deafening  noises.  Buptures  from  concussion  do  occur, 
however.  I  once  saw  a  woman  at  the  New  York  Eye  and  Ear 
Infirmary,  who  had  suffered  such  an  accident  from  the  firing 
of  a  pistol  near  her  ear  ;  and  Dr.  Hackley  observed  a  similar 
result  in  an  actor  who  was  obliged  to  fire  a  pistol  over  his 
shoulder  during  a  play.  The  power  of  the  muscles  of  the  Eus- 
tachian tube,  which  act  very  quickly,  and  force,  as  it  were,  a 
current  of  air  in  upon  the  drum  membrane  from  the  inner  side, 
is  probably  that  which  counterbalances  the  effect  of  a  sudden 
condensation  of  air  upon  the  outer  side.  The  little  chink,  which 
normally  exists  in  the  caliber  of  the  tube,  is  also  a  source  of  pro- 
tection. Those  persons  who  suffer  a  rupture  of  the  drum-head 
from  external  concussions,  probably  have  some  catarrhal  affec- 


224  RUPTURE  OF  MEMBRANA  TYMPANI. 

tion  which  prevents  the  air  from  freely  circulating  in  the  tubes 
arid  the  cavity  of  the  tympanum ;  for  we  can  scarcely  believe 
that  so  few  would  suffer  this  accident,  were  all  drum  membranes 
equally  liable  to  it.  During  the  heavy  fighting  of  our  civil 
war,  infantry  soldiers  in  the  trenches  were  in  the  habit  of  lying 
down,  while  the  artillery  behind  fired  over  their  heads ;  and 
yet,  as  I  have  found  by  inquiry,  rupture  of  the  membrana  tym- 
pani  was  scarcely  heard  of. 

Gruber's  experiments  on  the  cadaver  show  that  the  resist- 
ing power  of  the  membrane  is  very  great.  Dr.  Schmidekam 
assisted  Professor  Gruber*  in  these  experiments,  which  proved, 
according  to  the  former  author,  that  the  resisting  power  of  the 
membrane  was  greater  in  man  than  in  the  other  animals.  It 
required  a  column  of  quicksilver  of  143cm.  high  to  rupture  the 
membrana  tympani  of  an  ear  that  had  lain  in  alcohol  for  a  few 
weeks.  The  stapes  and  incus  had  been  removed.  The  rup- 
ture was  straight  and  parallel  to  the  lower  three-fourths  of 
the  anterior  line  of  attachment  of  the  malleus.  In  another 
case  a  drum-head,  which  exhibited  the  remains  of  a  former 
inflammatory  process,  in  the  form  of  a  false  membrane, 
was  not  ruptured  until  a  column  of  quicksilver  168cm.  high, 
was  used.  Here  again  the  rupture  occurred  on  the  anterior 
segment. 

Gruber  also  examined  the  resisting  power  of  the  drum-head 
by  the  following  experiment :  He  introduced  a  catheter  with  a 
bulbous  extremity  into  the  Eustachian  tube  of  a  fresh  subject, 
having  a  healthy  membrana  tympani,  and  fastened  the  catheter 
in  the  tube  by  means  of  a  stout  thread  stuck  through  it.  He 
then  allowed  a  stream  of  air  from  a  compression  pump — air 
that  had  been  condensed  four  or  five  fold — to  pass  suddenly 
into  the  tube,  or  after  closing  the  tube  by  tying  a  cord  about 
it,  he  stopped  the  external  auditory  canal  by  means  of  a  gutta- 
percha plug,  with  a  small  tube  in  it,  through  which  he  allowed 
the  compressed  air  to  pass.  Gruber  was  never  able  to  break 
the  membrane  in  this  experiment.  The  gutta-percha  plug 
with  the  tube  was  driven  out  of  the  canal,  but  the  membrane 
was  never  ruptured. 

*  Lehrbucli,  p.  332. 


RUPTURE   OF  MEMBKANA  TYMPANI.  225 

Professor  Gruber  saw  a  great  many  patients  who  were 
engaged  in  the  battles  of  Schleswig-Holstein  and  Bohemia  in 
1864  and  1866,  and  although  he  examined  nearly  all  the 
aural  patients  of  the  Garrison  Hospital  in  Vienna,  he  saw  but 
one  where  the  explosion  of  projectiles  had  caused  a  rupture 
of  the  drum-head.  In  this  case  the  soldier  was  knocked  sense- 
less by  the  explosion  of  a  grenade,  which  killed  two  near  him. 
"When  he  recovered  his  senses  he  was  suffering  from  tinnitus 
aurium  in  the  left  ear,  and  was  deaf  on  this  side.  Pain  oc- 
curred, and  in  three  weeks  after,  when  he  was  seen  by  Dr. 
Gruber,  he  was  found  to  have  a  roundish  opening  about  one 
and  a  half  lines  in  diameter,  in  the  anterior  and  inferior  seg- 
ment of  the  drum-head.  The  tubes  were  pervious,  and  there 
was  no  evidence  that  he  had  previously  suffered  from  aural 
disease.  This,  however,  was  the  only  case  among  hundreds 
of  soldiers  that  fought  at  Koniggratz,  who  had  suffered  the 
injury  which  has  been  detailed. 

Dr.  Andrew  H.  Smith,  one  of  my  colleagues  at  the  Man- 
hattan Eye  and  Ear  Hospital,  was  the  medical  officer  in 
charge  of  the  men  engaged  in  laying  the  foundations  for  the 
bridge  from  New  York  to  Brooklyn  over  the  East  Biver,  and 
had  many  opportunities  of  observing  the  effects  of  compressed 
air  upon  the  membrana  tympani.  Through  Dr.  Smith's  cour- 
tesy, I  saw  some  cases  that  illustrate  this  subject ;  and  I  here 
give  from  Dr.  Smith's  notes,  one  of  rupture  of  the  membrana 
tympani  which  occurred  while  the  patient  was  passing  through 
"  the  lock." 

Dr.  Smith  describes  the  case  of  rupture  of  the  membrane 
as  follows  : 

"John  H.,  on  May  17th,  the  pressure  being  about  35  pounds  to  the  square 
inch  above  the  normal ;  the  patient  was  attacked  while  in  the  lock  going  down 
for  the  first  time,  by  a  severe  pain  in  the  right  ear,  followed  by  a  slight  dis- 
charge from  the  meatus.  No  sensation  was  felt  as  of  anything  giving  way  in 
the  ear.  He  completed  his  watch,  and  then  reported  to  me.  On  examination, 
the  drum-head  was  found  to  be  ruptured  at  its  upper  edge.  The  opening  was 
nearly  circular  and  rather  less  than  a  line  in  diameter.  The  patient  preferred 
not  to  go  on  with  the  work,  and  he  was  not  seen  by  me  again." 

Dr.  Smith  believes  that  most  of  the  men  who  suffered  from 
aural  trouble  after  having  been  in  the  caisson,  had  previously 
some  impairment  of  the  permeability  of  the  Eustachian  tubes. 
15 


226  EFFECTS   OE  CONDENSED  AIE. 

The  men  imder  his  care  were  "  most  strenuously  "  instructed 
not  to  enter  the  caisson  unless  they  were  able,  when  holding 
the  nose  and  blowing  forcibly,  to  feel  the  air  enter  both  ears. 
Nevertheless,  cases  occurred  in  which  this  precaution  was 
neglected,  and  the  individual  was,  in  consequence,  caught  in 
the  lock  unable  to  "  change  his  ears."* 

Dr.  Smith  says  that  the  structures  within  the  tympanic 
cavity  not  being  acted  upon  by  the  increased  pressure,  "  are 
placed  relatively  in  the  same  position  as  the  skin  under  a 
cupping-glass,"  by  the  continued  exposure  to  the  effect  of 
compressed  air,  when  the  Eustachian  does  not  open,  or  rather, 
as  we  should  say,  when  it  does  not  act  well,  from  swelling 
or  thickening  of  its  tissue.  Then  the  intense  congestion 
occurs,  which  may  be  followed  by  inflammation,  finally  result- 
ing in  perforation  of  the  membrane,  as  happened  in  one  case 
reported  by  Dr.  Smith  in  his  paper. 

Politzer's  method  of  inflating  the  ears  was  found  very  use- 
ful in  treating  these  cases  of  simple  congestion,  which,  if  they 
had  not  been  treated,  would  have  resulted  in  tympanic  inflam- 
mation and  perforation  of  the  drum-head.  As  an  effect  of  the 
use  of  this  method  of  treatment,  many  of  Dr.  Smith's  men  were 
enabled  to  continue  at  their  work  who  could  not  have  otherwise 
done  so  without  danger.  The  treatment  became  very  popular 
among  the  men,  so  that  as  many  as  four  or  five  of  them  would 
come  at  Dr.  Smith's  visit  to  have  their  "  ears  blown  out." 

I  saw  three  or  four  of  these  cases  of  congestion  of  the  tym- 
panic cavity,  they  having  been  sent  to  me  by  Dr.  Smith,  and 
was  enabled  to  see  the  great  advantage  of  skilled  medical 
advice  to  these  men.  Many  ears  would  certainly  have  been 
permanently  injured  had  not  Politzer's  method  been  employed 
at  an  early  stage  of  the  trouble.t 

*  This  is  the  term  used  by  the  men  to  signify  the  operation  of  holding  the 
nose  and  blowing  until  the  air  is  felt  to  enter  the  middle  ear.  This  operation 
has  to  be  constantly  repeated  while  the  air  pressure  is  increasing  in  the  lock, 
in  order  to  relieve  the  pain  resulting  from  the  pressure  upon  the  membrana 
tympani.     In  some  persons  the  act  of  swallowing  answers  equally  well. 

f  Dr.  Smith's  paper  on  "  The  effects  of  High  Atmospheric  Pressure,  includ- 
ing the  Caisson  Disease,"  received  the  prize  of  the  Alumni  Association  of  the 
College  of  Physicians  and  Surgeons  for  1873,  and  will  soon  be  published.  My 
extracts  are  taken  from  the  manuscript  loaned  to  me  by  the  author. 


EFFECTS   OF  CONDENSED   AIE.  227 

A  gentleman  who  once  consulted  me  in  reference  to  what 
I  deemed  to  be  an  incurable  chronic  catarrh  of  the  middle  ear, 
which  had  resulted  in  thickening  and  sinking  of  the  drum- 
head, afterwards  came  to  me  with  a  perforation  of  the  mem- 
brane of  one  side  and  discharge  of  pus  from  the  tympanum, 
which  he  stated  was  caused  by  a  visit  to  the  caisson.  The 
perforation  soon  healed,  and  the  hearing  was  rather  worse 
than  before  the  accident. 

Dr.  John  Green,*  of  St.  Louis,  had  previously  to  Dr.  Smith 
made  some  observations  upon  "  the  physiology  of  the  Eusta- 
chian tube,  during  a  short  exposure  to  an  atmospheric  pres- 
sure of  sixty  pounds  to  the  square  inch."  Dr.  Green's  obser- 
vations were  made  while  bridge-piers  were  being  sunk  to  the 
rock  underlying  the  bed  of  the  Mississippi  now  at  St.  Louis 
in  1869-1870. 

The  entrance  to  the  chamber  of  condensed  air  was  "  through 
an  air  lock,  or  small  chamber  into  which  the  condensed  air 
could  be  admitted  gradually,  occupying,  for  the  higher  degrees 
of  pressure,  from  four  to  ten  minutes."  The  exit  occupied 
about  the  same  time. 

The  accidents  to  the  ears  occurred,  as  in  Dr.  Smith's  cases, 
while  passing  through  this  lock.  Sudden  chilling  of  the  body 
from  changes  in  temperature  in  the  chamber  were,  according 
to  Dr.  Green,  causes  of  catarrhs.  This  theory  is  rather  more 
sufficient  to  explain  the  cases  of  tympanic  congestion  when  the 
tube  was  not  completely  pervious,  than  the  one  of  mechanical 
pressure,  although  undoubtedly  both  causes  acted  together  in 
producing  aural  affections. 

Dr.  Green  notices  an  interesting  phenomenon  observed  in 
coming  out  of  the  lock,  which  Dr.  Smith  also  observed.  There 
was  a  spontaneous  escape  of  air  through  the  Eustachian  tubes 
in  a  succession  of  puffs,  succeeding  each  other  at  intervals  of 
fifteen  or  twenty  seconds,  independently  of  respiration,  and 
absolutely  without  the  concurrence  of  any  muscular  action. 
The  phenomenon  suggested  to  Dr.  Green  "the  action  of  a 
lightly  resisting  valve,  necessitating  a  slight  but  perceptive 
increase  of  pressure  within  the  tympanic  cavity,  to  open  the 

*  Transactions  of  the  American  Otological  Society,  1870. 


228  EFFECTS  OF  CONDENSED  AIR. 

passage  to  the  pharynx."  Dr.  Green  observed  several  cases 
of  rupture  of  the  drum-head  and  acute  catarrh  occurring  as  a 
result  of  the  unequal  pressure,  and  of  the  exposure  to  an 
uneven  temperature. 

Dr.  A.  Magnus*  of  Konigsburg,  investigated  very  carefully 
the  behavior  of  the  ear  in  condensed  air,  in  1863,  while  a  rail- 
way bridge  was  building  in  his  city.  He  proved  that  the  in- 
jury to  the  ear  was  caused  by  pressure  upon  the  membrana 
tynipani,  because  when  he  plugged  the  auditory  canal  hermet- 
ically, no  unpleasant  sensations  were  felt,  but  when  he  re- 
moved the  stopper  the  air  streamed  with  a  powerful  current 
into  the  canal,  and  pain  occurred  very  soon.  The  ear  that  was 
stopped  remained  without  pain,  and  the  Yalsalvian  experi- 
ment soon  relieved  the  pain  in  the  uncovered  one.  Magnus  also 
proved  by  an  examination  of  ears  when  the  pressure  was  being 
exerted,  that  the  membrana  tympani  was  actually  pressed 
inward.  The  triangular  spot  was  obliterated  when  the  pres- 
sure was  greatest  and  the  pain  severe.  A  patient  without  any 
membrana  tympani,  who  was  subjected  to  the  condensed  air, 
had  no  pain.  Indeed,  there  was  not  a  trace  of  an  unpleasant 
sensation. 

The  membrana  tympani  undoubtedly  owes  much  of  its 
resisting  power,  as  Mr.  Shrapnell  pointed  out,  to  the  existence 
of  a  triangular  membrane  at  its  upper  portion  that  is  less 
tense  and  thick  than  the  remainder  of  its  structure,  the  so- 
called  membrana  flaccida,  or  Shrapnell's  membrane,  which 
yields  when  undue  pressure  is  brought  upon  it.  The  mem- 
brane has,  perhaps,  some  additional  defence  in  its  oblique 
position  in  the  canal,  which  causes  a  portion  of  it  to  be  covered 
by  the  walls  in  such  a  way  as  not  to  receive  the  whole  force 
of  the  column  of  compressed  air.t 

The  membrana  tympani  is  perhaps  more  frequently  injured 
by  mechanical  violence  to  the  head  or  to  the  membrane  itself. 
My  friend  Dr.  Robert  F.  Weir,:}:  Surgeon  to  the  New  York 
Eye  and  Ear  Infirmary,  has  seen  four  such  cases.     In  one  the 

*  Archiv  fur  Ohrenbeilkunde,  Bd.  I.,  p.  270. 

f  The  effects  of  compressed  air  upon  the  hearing  power  will  be  again 
alluded  to  in  the  chapter  on  Chronic  Non -suppurative  iQuammation. 
%  Verbal  communication. 


INJURIES  OF  MEMBRANA  TYMPANI.  229 

drum-head  was  ruptured  by  a  blow  upon  the  head  with  the 
hand.  In  another,  fragments  of  rock  from  a  blast  struck  the 
head  and  ruptured  the  membrane.  In  the  third  case  the 
injury  was  caused  by  a  snow-ball  striking  the  ear ;  and  in  the 
fourth  a  hair-pin  was  accidentally  forced  through  the  part. 
In  the  first  three,  of  Dr.  Weir's  cases,  the  rupture  was  slit- 
shaped,  parallel  and  posterior  to  the  handle  of  the  malleus. 

I  have  now  under  my  observation  a  gentleman  of  about 
fifty  years  of  age,  whose  membrana  tympani  is  said  to  have 
been  ruptured  when  he  was  a  small  boy,  by  blows  upon  the 
side  of  his  head,  given  by  one  of  his  teachers.  The  membrane 
is  nearly  entirely  gone,  and  there  is  at  times  a  purulent  dis- 
charge from  the  tympanic  cavity.  Teachers  and  parents  who 
have  the  bad  habit  of  striking  children  unexpectedly  to  their 
little  charges,  should  be  warned  of  the  danger  of  a  box  on  the 
ear  to  the  integrity  of  the  organ. 

The  membrana  tympani  is  sometimes  ruptured  in  attempts 
to  remove  foreign  bodies,  such  as  inspissated  cerumen,  and  so 
on,  by  means  of  a  probe,  as  has  been  seen  in  one  of  the  pre- 
ceding chapters.  The  text-books  of  Toynbee  and  Von  Troltsch 
record  several  interesting  cases  of  injury  to  the  drum-head  by 
mechanical  violence.  The  latter  author  relates  one  in  which  a 
young  man,  while  going  up  a  ladder,  accidentally  struck  his  ear 
against  a  blade  of  straw,  which  passed  through  the  membrane 
and  caused  the  severest  pain,  so  that  he  nearly  fainted.  In 
one  of  Toynbee's*  cases  the  rupture  was  caused  by  an  unex- 
pected blow  upon  the  ear  of  a  boy  by  a  tutor.  In  another 
case  the  ear  was  hit  by  a  bolster  while  the  boys  were  engaged 
in  a  playful  contest.  In  both  of  these  cases  the  rent  was 
found  to  be  on  the  lower  part  of  the  membrane. 

Toynbee  also  relates  a  case  which  is  of  interest  on  account 
of  the  nervous  symptoms  produced  by  it.  A  young  man  of 
seventeen,  while  shooting,  in  endeavoring  to  force  his  way 
through  a  hedge,  got  a  twig  into  the  right  auditory  canal.  It 
produced  sudden  and  severe  pain,  followed  by  bleeding.  Mr. 
Toynbee  saw  the  patient  a  week  afterward.  The  pain  speedily 
subsided ;  but  for  days  after  the  accident  there  was  "  a  feeling 

*  Test-book,  p.  28- 


230  CHOKDA  TYMPANI  NERVE. 

on  the  same  side  of  the  tongue  as  if  something  cold  had 
been  rubbed  over  it ;  the  taste  on  that  side  also  was  im- 
paired." The  sensibility  of  the  tongue  to  touch  was,  how- 
ever, unimpaired. 

The  chorda  tympani  nerve  was  probably  injured  in  this 
case ;  for  the  same  sensations  are  sometimes  caused  when  a 
bit  of  cotton  or  woolen  is  brought  in  contact  with  the  cavity 
of  the  tympanum  and  with  the  nerve. 

The  function  of  the  chorda  tympani  is  probably  chiefly  in  connection  with 
that  of  taste,  and  not  of  hearing. 

Professor  Flint*  relates  a  case  which  sustains  this  view.  A  soldier  received 
a  gunshot  wound,  the  ball  passing  through  the  head,  entering  just  above  the 
ala  of  the  nose,  on  the  left  side,  and  emerging  behind  the  mastoid  process  of  the 
right  temporal  bone.  The  wound  healed,  with  the  usual  symptoms  of  com- 
plete facial  paralysis  on  the  right  side.  The  buccinator  and  orbicularis  oculi 
were  completely  paralyzed.  The  hearing  was  perfect.  The  sense  of  taste  was 
entirely  abolished  in  the  anterior  portion  of  the  tongue  on  the  right  side. 
These  facts  were  verified  by  Professor  Dalton  of  this  city. 

Experiments  upon  dogs  and  cats,  and  other  animals,  also  show,  according  to 
Flint,  that  the  chorda  tympani  influences  taste  ;  for  sections  of  the  root  of  the 
fifth  pair,  or  of  the  chorda  tympani,  is  followed  by  loss  of  taste  in  the  anterior 
portion  of  the  tongue. 

The  chorda  tympani  is  given  off  from  the  facial,  as  it  passes  vertically 
downwards  at  the  back  of  the  tympanum,  about  a  quarter  of  an  inch  before 
its  exit  from  the  stylo-mastoid  foramen.  It  ascends  from  below  upwards  in  a 
distinct  canal,  parallel  with  the  aquseduct  of  Fallopius,  and  enters  the  cavity 
of  the  tympanum  through  an  opening  between  the  base  of  the  pyramid  and 
the  attachment  of  the  membrana  tympani.  It  becomes  covered  by  mucous 
membrane,  and  passes  forward  through  the  tympanic  cavity  between  the  han- 
dle of  the  malleus  and  the  vertical  crus  of  the  incus  (see  Fig.  44,  on  p.  194),  and 
then  passes  out  of  the  cavity,  through  the  canal  of  Hugier,  at  the  inner  side  of 
the  Glaserian  fissure.  It  then  passes  downward,  between  the  two  pterygoid 
muscles,  and  meets  the  gustatory  nerve  at  an  acute  angle,  and  communicating 
with  this  it  passes  to  the  submaxillary  gland  ;  after  joining  the  submaxillary 
ganglion  it  terminates  in  the  lingualis  muscle. 

Its  anatomy  seems  to  indicate  that  it  has  very  little  to  do  with  the  function 
of  hearing.  It  merely  passes  through  the  tympanum,  without  supplying  any 
of  its  tissues,  as  has  already  been  described  in  the  chapter  on  the  anatomy  of 
the  middle  ear. 

Claude  Bernard  also  performed  experiments  upon  the  chorda  tympani  of 
cats  and  Albino  rats,  by  cutting  out  the  facial  nerve  at  its  exit  from  the  stylo- 
mastoid foramen.  In  from  six  to  ten  days  the  terminal  twigs  of  the  lingualis 
nerve,  and  the  nerve  fibres  coming  from  the  chorda  tympani  were  found  to 

*  The  Physiology  of  Man,  The  Nervous  System,  p.  157. 


EUPTUKE   OF   MEMBRANA  TYMPANI.  231 

have  undergone  fatty  degeneration.  Degenerated  nerve  fibres  were  also  found 
in  the  tip  of  the  tongue,  but  not  in  the  papillae.  There  were  also  degenerated 
nerve  fibre  in  the  submucous  tissue.* 

Severe  vomiting  sometimes  causes  a  rupture  of  the  drum- 
head, as  does  strangulation  by  hanging.  The  cases  of  rupture 
that  occur  during  whooping-cough,  and  sneezing  or  blowing  the 
nose,  are  not  properly  to  be  considered  in  the  present  chapter ; 
for  when  the  membrana  tympani  is  ruptured  in  such  cases, 
there  is  usually,  if  not  always,  some  pre-existing  catarrh  of 
the  Eustachian  tube  and  tympanic  cavity.  I  have  seen  seve- 
ral such  cases,  but  in  all  of  them  I  have  been  able  to  trace 
disease  of  the  middle  ear  as  having  preceded  the  breaking  of 
the  drum-head.  The  great  accumulation  of  mucus  caused  by 
the  catarrhal  inflammation  will  be  very  apt  to  cause  a  rupture 
by  mechanical  pressure  from  within  upon  a  distended  mucous 
membrane  and  fibrous  layer,  unless  the  cavity  be  emptied  by 
means  of  the  catheter  or  Politzer's  method. 

In  countries  where  punishment  is  meted  out  in  exact  pro- 
portion to  the  amount  of  personal  injury  done  to  the  person 
assaulted,  blows  upon  the  side  of  the  head  which  result  in 
rupture  of  the  membrana  tympani  are  made  the  subject  of 
careful  medico-legal  examination.! 

In  order  to  determine  the  cause  of  a  rupture  of  the  mem- 
brana tympani,  it  must  be  seen  within  a  few  hours  of  the 
injury  ;  for  suppuration  may  occur  soon  after  it  has  occurred, 
when  it  will  be  impossible  to  decide  whether  it  had  a  trau- 
matic or  spontaneous  origin. 

A  traumatic  rupture  of  the  membrana  tympani,  especially 
one  arising  from  the  perforation  of  the  membrane  by  a  sharp 
instrument,  is  much  more  apt  to  cicatrize  promptly,  without 
suppuration,  than  one  that  has  been  perforated  in  the  course 
of  inflammation  of  the  middle  ear. 

The  force  of  large  waves  upon  the  side  of  the  head  in  sea- 

*  Monatsschrift  fur  Ohrenheilkunde,  No.  1, 1873,  from  Comptes  Rendus, 
Hebdom.  des  Seances  de  l'Academie  des  Sciences,  T.  lsxv.,  No.  27.    Paris,  1872. 

f  According  to  the  Austrian  criminal  code,  an  injury  is  defined  to  be  a 
severe  one,  when  the  person  suffering  it  is  deprived  of  his  usual  health,  or  kept 
from  his  occupation  for  a  period  of  not  less  than  twenty  days. — Politzer,  Wiener 
Med.  Wochenschrift,  Nos.  35,  36,  1872. 


232  EUPTUEE   OF  MEMBKANA   TYMPANI. 

bathing,  is  not  an  uncommon  cause  of  rupture  of  the  mem- 
brana tympani.  I  have  seen  such  cases,  and  one  where  both 
membranes  were  ruptured.  A  wave  is  sometimes  allowed  to 
strike  upon  the  membrane  with  great  violence,  and  if  it  do  not 
break  it,  it  will  at  least  excite  an  inflammatory  action.  Phy- 
sicians who  practice  at  the  sea-side,  should  warn  their  patients 
of  this  danger  from  surf-bathing.  Long  Branch  and  Newport, 
furnish  every  year  a  certain  contingent  of  aural  patients  from 
this  cause. 

A  little  care  in  not  allowing  the  waves  to  strike  the  side 
of  the  head  in  full  force,  or  plugging  the  meatus  lightly  with 
cotton,  will  be  found  to  be  a  sufficient  protection  from  the 
severity  of  the  waves.  If  water  be  allowed  to  stay  in  the 
auditory  canal  for  some  time,  it  becomes  a  source  of  conges- 
tion ;  but  such  causes  of  diseases  of  the  middle  ear  are  more 
appropriately  considered  in  a  subsequent  chapter. 

Dr.  C.  H.  Burnet*  of  Philadelphia,  has  lately  reported  a 
case  of  evulsion  of  the  membrana  tympani,  from  the  splashing 
of  mud  into  the  ear  by  a  horse  while  the  patient  was  crossing 
the  street.  The  patient  was  39  years  old,  and  consulted  Dr. 
Burnet  three  days  after  the  accident.  He  stated  that  his  ear 
was  sound  until  the  mud  came  into  it.  Upon  returning  to  his 
shop — he  was  a  machinist — he  was  examined  by  some  of  his 
comrades,  who  said  they  saw  foreign  objects  in  the  meatus, 
which  they  proceeded  to  extract  with  chips  and  mechanics'  small 
tools.  Several  "little  white  pebbles"  were  taken  out,  which 
were  probably  the  ossicles.  Great  impairment  of  the  hearing 
of  the  ear  followed.  The  patient  was  very  pale,  anxious  and 
bathed  in  cold  perspiration  when  he  visited  Dr.  Burnet.  A 
watch  that  should  have  been  heard  40  feet  was  only  heard 
5cm.  The  tuning-fork  placed  on  the  vertex  was  heard  very 
distinctly  in  the  injured  ear. 

On  examination,  Dr.  Burnet  found  the  meatus  uninjured. 
A  small  piece  of  mud  was  adherent  to  the  antero-superior 
quadrant  of  the  periphery  of  the  membrana  tympani.  The 
membrane  was  entirely  destroyed,  except  a  very  narrow  bor- 
der.    There  were  no  ossicles  visible.     The  inner  wall  of  the 

*  Transactions  of  the  American  Otological  Society,  1872. 


EUPTURE   OF  MEMBRANA  TYMPANI.  233 

yympanum  was  fully  exposed  to  view.  The  mucous  membrane 
was  healthy,  but  slightly  abraded  on  the  promontory.  Twenty 
days  after,  without  treatment,  patient  was  free  from  pain  and 
"  ruddy  and  cheerful."  The  border  of  the  membrana  tympani 
had  become  adherent  to  the  promontory.  Of  course  the  hear- 
ing power  was  not  improved,  thanks  to  the  care  of  his  surgical 
comrade,  who  so  carefully  removed  the  "  white  pebbles  "  from 
his  ear. 

The  explosion  of  a  bag  of  gas  near  the  ear,  may  also  cause 
a  rupture  of  the  membrana  tympani.  Dr.  J.  Orne  Green,*  of 
Boston,  reports  such  a  case.  The  patient,  who  was  preparing 
for  an  exhibition  in  which  an  oxy-hydrogen  light  was  to  be 
used,  was  standing  a  few  feet  from  the  bag,  and  with  his  left 
side  towards  it  at  the  time  of  the  explosion.  The  immediate 
effect  was  some  slight  confusion  of  intellect,  which  soon  passed 
off ;  but  the  next  day  the  left  ear  began  to  be  painful,  and  on 
blowing  the  nose,  air  whistled  through  it. 

Dr.  Green  saw  the  patient  twelve  days  after  the  accident, 
and  found  the  membrana  tympani  red  and  swollen,  and  on  the 
posterior  segment  just  behind  the  umbo,  a  rupture  1\  lines 
long,  nearly  perpendicular,  through  which  purulent  matter 
could  be  forced  by  Valsalva's  method  of  inflation.     H.  D.  ?6gv 

Dr.  Green  states  that  this  patient  had  previously  suffered 
from  impaired  hearing  and  mucous  rales  in  his  ears.  Many 
of  the  cases  of  rupture  of  the  drum-head  on  record,  if  the 
antecedents  had  been  inquired  into,  would  undoubtedly  ex- 
hibit the  same  condition  of  things. 

The  assistant  of  the  patient  whose  case  has  just  been 
quoted,  suffered  at  the  same  time  from  the  explosion  of  a  bag 
of  gas,  and  also  received  rupture  of  the  membrane,  which 
resulted  in  a  purulent  inflammation  of  the  tympanic  cavity. 
He  was  treated  by  Dr.  Henry  L.  Shaw  of  Boston.  In  both 
of  these  cases  the  rupture  healed  perfectly,  and  the  hearing 
power  was  partially  restored.   In  Dr.  Green's  case  it  became  ||. 

Dr.  Green  saw  two  other  cases  in  which  the  patients  suf- 
fered from  the  concussion  of  the  same  accident.  It  caused 
a  loud  buzzing  in  the  ear  and  confusion  in  the  head.     The 

*  Transactions  of  the  American  Otblogical  Society,  1872. 


234  KUPTURE   OF  MEMBRANA  TYMPANI. 

patients  consulted  Dr.  Green  on  account  of  the  tinnitus  which, 
was  caused  in  one  case,  but  aggravated  in  the  other,  for  the 
latter  patient  had  previously  suffered  from  disease  of  the  mid- 
dle ear.* 

Fracture  of  the  base  of  the  brain  involving  the  temporal 
bone,  very  often  produces  rupture  of  the  membrana  tympani 
and  consequent  hemorrhage  from  the  ears ;  but  a  considera- 
tion of  such  cases  belongs  to  the  province  of  general  surgery. 

Prognosis. — The  prognosis  in  a  case  of  rupture  of  the  mem- 
brana tympani  depends  very  much  upon  the  nature  of  the  in- 
jury that  caused  it.  An  accident  of  this  kind,  when  produced 
by  the  concussion  of  a  heavy  explosion  or  of  a  severe  blow 
upon  the  side  of  the  head,  is  much  more  serious  in  its  nature, 
than  an  injury  to  a  drum-head  from  the  forcing  through  it  of  any 
sharp  body,  such  as  a  knitting-needle,  pen-holder,  twig  of  a  tree, 
a  blade  of  straw  or  the  like.  The  former  class  of  injuries  are  apt 
to  produce  a  concussion  of  the  labyrinth,  or  a  fracture  or  dis- 
location of  the  ossicula,  as  well  as  a  rupture  of  the  drum-head. 
Such  a  result  at  once  takes  the  affection  away  from  the  category 
of  simple  injuries,  and  renders  it  a  very  serious  one,  not  only 
with  reference  to  the  hearing  power,  but  also  as  regards  life. 
The  tuning-fork  becomes  a  valuable  assistant  to  diagnosis  in 
cases  of  rupture.  Its  vibrations  will  be  heard  more  distinctly 
in  the  injured  ear  than  the  other,  if  the  labyrinth  be  not 
injured.  A  simple  rupture  usually  heals  in  a  few  days  with- 
out great  injury  to  the  hearing.  A  suppurative  process  may 
result,  however,  and  become  chronic,  when  the  treatment  should 
be  the  same  as  that  of  any  other  similar  affection  arising  spon- 
taneously. 

Treatment. — We  can  do  very  little  indeed,  in  the  way  of 
treatment,  if  no  inflammatory  symptoms,  such  as  pain  or  swell- 
ing, occur.  Above  all,  we  should  not  disturb  the  ear  immedi- 
ately after  the  occurrence  of  the  injury,  as  is  sometimes  mis- 

*  Dr.  Green  records  several  other  cases  of  injury  of  the  side  of  the  head 
which  produced  a  rupture  of  the  membrana  tympani,  but  as  they  do  not  differ 
from  others  that  are  noticed  in  this  chapter,  I  beg  to  refer  my  readers  who 
may  wish  to  carry  this  subject  farther,  to  bis  interesting  paper 


FEACTUEE   OF   HANDLE   OF  MALLEUS.  235 

takenly  done,  by  syringing  it.  There  is  a  very  prevalent  dis- 
position in  the  profession,  to  syringe  the  ear  in  every  case  of 
aural  disease  that  presents  itself ;  but  no  ear  should  be  syringed 
without  a  good  and  sufficient  reason.  When  inflammatory 
symptoms  occur,  they  should  be  treated  by  leeches,  the  warm 
douche,  and  by  the  other  means  that  will  be  detailed  in  the 
chapter  on  Acute  Inflammation  of  the  Middle  Ear.  Mean- 
while the  ear  should  be  protected  from  the  cold  air,  by  a  bit  of 
cotton  placed  in  the  meatus,  and  the  patient  should  be  kept 
under  careful  but  not  meddlesome  observation. 

FRACTURE   OF  THE   HANDLE   OF   THE  MALLEUS. 

This  rare  accident  has  been  described  by  Meniere,  Yon 
Troltsch,  and  Weir.*  The  history  of  the  case  of  the  second- 
named  author  is  as  follows :  A  man  accidentally  thrust  a 
pen-handle  which  he  held  in  his  hand  into  his  ear,  in  con- 
sequence of  knocking  his  elbow  against  a  door.  The  severe 
pain  caused  him  to  faint.  After  he  recovered,  he  found 
that  he  heard  badly  from  the  injured  ear,  and  he  suffered 
from  tinnitus  of  that  side.  Von  Troltsch  saw  the  case  a  year 
after,  and  from  the  peculiar  slanting  position  of  the  handle  of 
the  malleus,  and  from  the  fact  that  it  was  uncommonly  thick 
under  the  short  process,  he  diagnosticated  a  united  fracture 
of  the  manubrium. 

Hyrtl,  is  quoted  by  Yon  Troltsch,  as  having  described  such 
a  united  fracture  in  the  malleus  of  a  prairie  dog.  This  frac- 
ture was  also  situated  just  under  the  neck  of  the  malleus.  The 
membrana  tympani  of  this  animal  is,  according  to  Hyrtl,  very 
superficially  situated. 

Dr.  Weir's  case  is  one  of  ununited  fracture.f  A  man,  aged 
32,  came  to  Dr.  Weir's  cliniqne,  at  the  New  York  Eye  and 
Ear  Infirmary,  on  May  11,  1867,  and  gave  the  following- 
history  :  Four  months  previously  he  fell  into  an  open  area- 
way,  a  distance  of  about  fifteen  feet.  He  became  uncon- 
scious, and  remained  so  for  nearly  sixteen  hours.  He  had 
been  informed  that  his  right  ear  bled  for  about  an  hour. 

*  Von  Troltsch  on  the  Ear,  2d  American  Edition,  p.  151. 
f  Transactions  American  Otological  Society. 


236  FRACTURE  OF  HANDLE   OF  MALLEUS. 

Upon  returning  to  consciousness  he  felt  a  severe  pain  from  the 
right  ear,  across  the  forehead  to  the  other  ear.  The  pain 
lasted  for  nearly  a  month,  and  gradually  diminished  ;  but  the 
great  tinnitus,  which  date  from  the  time  of  the  injury,  con- 
tinue unabated.  There  was  no  history  of  any  foreign  body 
having  entered  the  ear.  The  watch  was  heard  upon  the 
affected  side  when  pressed  firmly  upon  the  ear. 

The  drum  membrane  was  normal  in  color  ;  but  there  was 
an  irregularity  in  the  handle  of  the  malleus.  The  bone  was 
found  to  be  fractured  a  short  distance  below  the  short  pro- 
cess, presenting  the  appearance  shown  in  the  engraving.  The 
broken  ends  of  the  bone  were  completely  and  transversely 
displaced. 

Fig.  56.  Fig.  57. 


When  Dr.  "Weir  caused  the  patient  to  perform  the  Valsal- 
vian  experiment,  the  fragments  came  into  apposition,  and  the 
line  of  the  bone  became  regular ;  but  the  posterior  portion  of 
the  membrana  tympani  projected  unduly  forward  from  want 
of  support.  In  a  few  moments  the  displacement  recurred, 
with  corresponding  sinking  of  the  posterior  of  the  drum  mem- 
brane. Dr.  Weir's  colleagues — Drs.  Hackley  and  Simrock — 
thought  that  a  faint  whitish  line,  posterior  to  the  malleus, 
might  be  a  cicatrix  from  a  laceration  of  the  drum-head.  The 
patient  did  not  return  to  the  Infirmary. 


CHAPTER    XL 

ACUTE  CATARRHAL  INFLAMMATION  OF  THE  MIDDLE  EAR. 

The  nomenclature  that  I  have  adopted  in  lecturing  upon 
the  affections  of  the  middle  ear,  and  the  one  which  I  regard 
as  most  in  accordance  with  the  anatomy  and  pathology  of  this 
part  of  the  organ  of  hearing,  may  be  tabulated  as  follows  : 

I. — Acute  catarrhal  inflammation. 
II. — Subacute  catarrhal  inflammation. 
III. — Chronic  non-suppurative  inflammation,  divided  into 

two  forms — catarrhal  and  proliferous. 
IV. — Acute  suppurative  inflammation. 
V. — Chronic  suppurative  inflammation. 
YI. — The  consequences  of  chronic  suppuration : 

1.  Polypi. 

2.  Exostoses. 

3.  Mastoid  disease. 

4.  Caries  and  necrosis. 

5.  Cerebral  abscess. 

6.  Pysemia. 

7.  Paralysis. 

By  such  a  classification  as  this,  especially  that  relating  to 
the  suppurative  affections,  correct  notions  are  formed  as  to  the 
nature  of  such  diseases  as  polypi  and  mastoid  disease,  which 
is  otherwise  difficult.  Polypi  and  exostoses  have  hitherto 
been  classified  under  the  diseases  of  the  external  auditory 
canal.  They  are  certainly,  in  most  cases,  situated  in  this 
part ;  but  this  is  their  chief  claim  to  such  a  classification.  In 
by  far  the  greater  number  of  cases  they  are  the  direct  result 
of  inflammation  of  the  middle  ear. 

If  we  were  to  form  our  estimate  of  the  frequency  of  acute 
catarrhal  inflammation  of  the  middle  ear  from  the  number  of 


238         ACUTE  CATARRH  OF  THE  MIDDLE  EAB. 

cases  tliat  occur  in  the  statistics  of  writers  on  diseases  of  the 
ear,  we  should  come  to  a  very  erroneous  conclusion  as  to  the 
number  of  people  who  suffer  from  this  affection.  It  is  indeed 
a  very  common  one.  It  is  difficult  to  find  an  adult  who  has 
not  at  one  time  or  another  suffered  from  "ear-ache."  Ear- 
ache is  the  popular  name  for  acute  catarrh  of  the  middle  ear. 
My  own  statistics  show  that  of  994  cases  of  aural  disease  seen 
in  private  practice,  only  55,  or  a  little  more  than  five  in  a  hun- 
dred, belonged  to  the  class  now  under  consideration.  The 
tables  of  other  writers  show  about  the  same  relative  frequency. 
That  this  disproportion  does  not  arise  from  an  actual  rarity  of 
the  affection,  I  think  a  little  thought  will  show.  Such  pain- 
ful affections  very  often  never  reach  a  practitioner,  and  are 
treated  at  home,  a  fact  which  accounts  for  their  infrequency  in 
statistical  tables. 

Every  physician  will  at  once  recall  the  fact,  that  it  is  often 
incidentally  mentioned,  when  perhaps  he  is  visiting  a  family 
suffering  from  other  diseases,  that  Johnny  or  Mary  have  had  a 
severe  ear-ache  all  night,  and  that  there  has  been  great  difficulty 
in  quieting  the  fearful  pain.  Very  often,  indeed,  the  fact  will 
be  added,  that  the  pain  is  not  yet  subdued,  and  that  the  family 
have  quite  exhausted  the  means  at  their  disposal  for  relieving 
ifc ;  and  yet,  taught  by  tradition  and  experience,  they  do  not 
expect  anything  from  the  physician,  whose  aid  becomes  so 
efficacious  for  the  pain  of  colic  or  of  peritonitis.  It  is  to  be 
feared  that  many  physicians  stand  helplessly  by,  and  allow 
an  acute  catarrh  of  the  middle  ear  to  run  on  to  suppuration 
of  the  drum-head,  or,  worse  still,  to  periostitis  of  the  mas- 
toid or  to  meningitis,  without  an  attempt  at  interference. 

A  little  later,  in  the  discussion  of  this  affection,  we  shall 
discover,  I  think,  that  the  means  at  our  disposal  for  its  relief 
are  ample,  and  that  they  have  what  may  almost  be  termed  a 
brilliant  effect,  when  properly  used ;  but  I  wish  in  the  outset 
to  impress  upon  the  minds  of  my  readers  the  fact  that  the 
commonly  neglected  ear-ache  of  the  household  is  identical 
with  the  disease  known  as  acute  catarrhal  inflammation  of 
the  middle  ear.  It  will  then  be  evident  that  we  are  dealing 
with  an  extremely  practical  subject,  and  one  on  which  every 
family  practitioner  is,  or  should  be,  very  much  interested. 


SYMPTOMS  OF  ACUTE  CATABBH.  239 

The  symptoms  of  this  affection  are  so  characteristic  that 
in  the  adult,  they  point  unmistakably  in  the  most  cases  to  its 
seat.  I  say  in  the  adult,  for  in  young  children  who  have  not 
yet  learned  to  speak,  the  diagnosis  sometimes  becomes  very 
difficult,  and  it  is  not  always  possible. 

Symptoms. — The  symptoms  of  acute  catarrh  may  be  enume- 
rated in  the  following  order  : 

Subjective. 

1.  Pain,  referred  to  the  depth  of  the  ear. 

2.  A  sense  of  fulness  in  the  same  part. 

3.  Noises  in  the  ear. 

Objective. 

1.  Vascular  injection. 

2.  Bulging  outwards  of  the  membrana  tympani. 

3.  Impairment  of  hearing. 

4.  Catarrh  of  the  pharynx  and  Eustachian  tubes. 

5.  Fever. 

The  pain  is  very  often  the  first  symptom  that  is  observed. 
Children  old  enough  to  speak,  awake  from  sleep  crying,  "  My 
ear,  my  ear."  Adults  find  themselves  without  warning  at- 
tacked by  a  pain  which  causes  the  most  intense  agony — a  pain 
which  forces  the  strongest  men  to  shriek  and  tremble,  while 
children  affected  with  such  a  disease  soon  cause  the  attend- 
ants to  believe  that  the  brain  must  be  the  seat  of  trouble. 
Sometimes,  however,  patients  with  good  habits  of  observation 
notice  that  the  pharynx  felt  thickened  and  full,  and  that  the 
throat  was  sore,  a  short  time  before  the  pain  in  the  ear  began. 
I  am  inclined  to  believe  that  the  most  patients  are  aware  of 
what,  for  the  want  of  a  better  name,  may  be  termed  a  thickness 
of  hearing,  a  fullness  in  the  ears,  before  the  attack  of  pain  oc- 
curs. This  pain  is  described  by  some  patients  as  beginning  in 
the  throat  and  crawling  along  the  Eustachian  tube.  It  is  a 
disease,  however,  which  may  be  said  to  be  sudden  in  its  ori- 
gin, and  one  which  jumps  at  a  bound  to  its  height.  It  will 
pass  over  the  acme,  in  the  most  cases,  unless  at  once  arrested, 
into  acute  suppuration  of  the  middle  ear ;  a  disease  which, 
strangely  enough,  some  practitioners  seem  to  invite,  by  the 


240         SYMPTOMS  OF  ACUTE  AURAL  CATARRH. 

remark  which  they  make,  "  It  is  a  common  gathering  of  the 
ear,  from  which  we  shall  get  no  relief  until  suppuration  is 
established."  I  intend  to  combat  this  idea  in  the  discussion 
of  the  treatment.  It  is  certainly  an  erroneous  and  mischiev- 
ous view  of  a  serious  disease. 

The  sensations  of  fulness,  the  noises  in  the  ear  in  acute 
inflammation,  are  very  distressing.  The  latter  symptom,  the 
technical  tinnitus  aurium,  usually  lessens  and  changes  its  char- 
acter with  a  cessation  of  the  pain.  It  changes  from  a  puffing 
sound,  like  the  puff  of  a  miniature  steam  engine,  to  a  ringing 
or  buzzing  sensation.  The  feeling  of  fulness  may  last  for 
some  days  after  the  pain  has  passed  away. 

As  I  have  said,  the  diagnosis  of  this  disease  is  often  diffi- 
cult in  young  children,  because  they  are  unable  to  locate  the 
seat  of  the  pain  in  words.  If,  however,  we  watch  a  child  care- 
fully who  is  suffering  from  pain  in  the  ear,  we  can  usually  narrow 
it  down  to  the  region  of  the  head.  Then  by  means  of  pressure 
upon  the  tragus,  observing  if  the  child  winces  at  this,  we  can 
generally  form  a  conclusion  as  to  the  origin  of  the  pain.  The 
disease  with  which  infantile  catarrh  of  the  middle  ear  is  apt  to 
be  confounded  is  an  affection  of  the  membranes  of  the  brain. 
Besides  this,  the  physiological  process  of  teething,  is  often  cred- 
ited with  a  great  deal  of  pain,  which  more  properly  belongs  to 
the  ear.  With  a  certain  style  of  what  may  be  called  easy  going 
practitioners,  the  diagnosis  of  difficult  dentition,  is  often  suffi- 
cient to  cover  a  multitude  of  painful  symptoms.  Accordingly, 
gums  are  needlessly  lanced,  and  dangerous  delays  are  allowed, 
until  a  discharge  of  pus  through  the  drum-head,  makes  the 
diagnosis  for  the  little  sufferer. 

The  instillation  of  warm  water  into  the  auditory  canal  will 
usually  temporarily  relieve  an  infantile  ear-ache ;  and  in  this 
procedure  we  have  a  means  of  diagnosis  which  is  always  at 
hand.  I  have  seen  children  who  were  crying  with  pain  from 
inflammation  of  the  middle  ear,  go  to  sleep  in  a  few  moments 
after  the  instillation  of  warm  water  into  the  meatus.  Some- 
times, however,  this  procedure  will  fail  to  give  relief,  and  we 
must  depend  upon  the  objective  symptoms,  of  which  I  shall 
soon  speak,  found  in  the  color  of  the  membrana  tympani. 

Adults  sometimes  mistake  the  pain  from  inflammation  of 


SYMPTOMS  OF  ACUTE  AURAL  CATARRH.         241 

the  lining  membrane  of  the  middle  ear,  for  what  is  termed  neu- 
ralgia. I  have  seen  cases  where  an  anti-neuralgic  treatment 
by  means  of  quinine  and  opium,  had  been  tried  in  vain  for  a 
disease  which  was  really  a  true  inflammation  of  mucous  mem- 
brane ;  but  adults  usually  locate  the  seat  of  trouble  with  exact- 
ness and  accuracy.  The  pain  is  indeed  neuralgic,  and  a  mo- 
ment's consideration  of  the  rich  supply  of  nerves  to  the  cavity 
of  the  tympanum,  will  give  the  reason  for  the  fact  that  the 
pain  follows  the  course  of  the  5th  and  7th  nerves. 

The  objective  symptoms  are  chiefly  to  be  sought  in  the 
membrana  tympani.  There  is  sometimes  a  pinkish  hue  to 
the  whole  membrane,  again  the  vascular  injection  is  around 
the  periphery  of  the  drum-head,  and  along  the  handle  of  the 
malleus,  while  the  other  parts  of  the  membrane  remain  of 
their  normal  color.  An  acute  inflammation  occurring  in  a 
drum  membrane  rigid,  thickened,  and  opaque  from  former 
inflammation,  is  more  apt  to  show  localized  redness  than  the 
diffuse  pinkish  tint,  that  is  seen  when  inflammation  occurs  in 
a  membrane  that  has  been  previously  healthy. 

At  other  times  the  redness  is  so  intense  as  almost  to  pre- 
vent any  recognition  of  the  drum-head,  except  as  an  evenly 
red  surface  in  which  no  vessels  can  be  traced. 

I  think  there  is  always  some  increased  vascularity  of  this 
membrane,  in  every  case  of  acute  inflammation  of  the  lining 
of  the  tube  and  the  cavity  of  the  tympanum,  so  that  we  may 
find  in  this  symptom  the  deciding  point  in  doubtful  cases, 
even  in  the  infants.  The  membrane  has,  however,  at  times 
the  appearance  of  glass  that  has  been  breathed  upon,  without 
any  evident  increase  in  vascularity,  even  where  there  is  acute 
inflammation  going  on  in  the  middle  ear. 

The  impairment  of  hearing  is  not  always  marked  in  the 
stage  of  pain.  The  hearing  power  may  even  be  augmented 
and  be  painfully  acute  during  the  first  stage  of  the  disease. 
I  have  known  many  instances  where  the  acuteness  of  hearing 
was  found  on  accurate  examination  to  be  markedly  increased 
in  cases  of  chronic  aural  catarrh,  in  which  an  acute  inflam- 
mation had  supervened.  It  may  be  increased  also  in  acute 
cases  occurring  in  persons  whose  ears  have  been  previously 
healthy ;  that  is  to  say,  sounds  may  seem  very  loud  to  them. 
16 


242         SYMPTOMS  OF  ACUTE  AURAL  CATARRH. 

I  will  not  attempt  any  explanation  of  the  phenomenon,  but  be 
content  with  noting  the  fact. 

Bulging  outward  of  the  membrana  tympani  is  a  symptom 
that  may  often  be  observed  after  the  first  forty-eight  hours  of 
an  attack  of  acute  catarrh.  If  the  disease  continue  longer 
in  an  acute  form,  spontaneous  perforation  is  apt  to,  but 
does  not  always  occur.  This  bulging  outward,  I  have  most 
frequently  observed  in  the  posterior  and  inferior  quadrant, 
b.ut  also  in  Shrapnell's  membrane,  and  usually  in  the  posterior 
portion  of  the  membrane.  It  is  sufficiently  marked  to  be 
detected  by  any  one  who  is  at  all  familiar  with  the  examina- 
tion of  the  normal  membrane.  In  rare  cases— I  believe  I  have 
seen  but  two  in  my  experience — the  imperforate  membrana 
tympani  will  be  found  to  pulsate  synchronously  with  the  pul- 
sations of  the  heart.  As  is  well  known,  it  is  quite  common  to 
observe  a  pulsation  of  the  vessels  of  the  cavity  of  the  tympa- 
num in  cases  of  acute  and  chronic  suppuration  of  this  part ; 
but  pulsation  of  the  imperforate  membrana  tympani  is  a  rare 
symptom.  There  must  be  great  increase  of  the  tension  of  the 
membrane  when  this  occurs,  from  the  pressure  of  the  blood 
column  or  of  mucus  behind  it.  Increased  secretion  from  the 
pharynx  and  region  of  the  posterior  nares  is  almost  always 
observed  in  cases  of  acute  catarrh  ;  but  it  requires  but  a  mere 
mention  at  this  point. 

Febrile  symptoms  are  almost  always  present  in  cases  of 
the  disease  under  discussion.  The  temperature  is  usually 
quite  considerably  increased,  so  that  the  general  aspect  of  the 
patient,  suffering  from  great  local  pain,  impairment  of  hear- 
ing, and  a  dry,  heated  skin,  is  one  of  intense  suffering.  Yet 
this  is  the  disease  which  many  physicians  allow  to  run  its 
course,  without  any  of  the  antiphlogistic  treatment  that  they 
would  at  once  resort  to,  were  any  other  organ  of  the  body  sim- 
ilarly attacked. 

Causes. — The  causes  of  this  disease  are  manifold.  Any 
undue  exposure  to  the  influence  of  cold  may  produce  acute 
catarrh  of  the  middle  ear.  Getting  the  feet  wet,  the  sur- 
face of  the  body  chilled  by  standing  or  walking  in  the  cold, 
are  frequent  causes  of  ear-ache.     A  draught  of  air  blowing, 


CAUSES  OF  ACUTE  CATARRH.  243 

for  instance,  through  the  window  of  a  railway  carriage  in 
rapid  motion,  is  sometimes  a  cause  of  acute  catarrh. 

Ducking  the  head  under  water,  and  allowing  the  water  that 
enters  the  auditory  canal  to  remain  there,  is  another  cause. 
Constitutional  diseases,  such  as  small-pox,  scarlet  fever,  and 
measles,  in  which  the  pharynx  is  affected,  are  very  common 
sources  of  acute  aural  catarrh.  Pneumonia  and  bronchitis  very 
often  have  this  affection  as  a  consequence.  Coryza  or  cold  in 
the  head,  however  caused,  very  often  gives  rise  to  acute 
inflammation  of  the  ear. 

It  arises  in  the  course  of  syphilitic  affections  of  the  pha- 
rynx and  posterior  nares ;  but,  contrary  to  what  has  been  said 
by  some  authors,  I  have  found  no  pathognomic  evidences  of 
syphilis  in  the  character  of  the  pain  or  the  appearance  of  the 
membrana  tympani  in  such  cases. 

The  origin  of  acute  catarrh  is  chiefly  to  be  sought  for  in 
the  faucial  extremity  of  the  Eustachian  tube,  and  not  in  the 
auditory  canal.  This  explains  the  fact,  that  it  is  much  more 
important  for  patients  liable  to  aural  disease  to  protect  the 
external  surface  of  the  body  and  the  extremities  from  the  cold, 
than  the  meatus  and  auricle. 

Yet  it  is  not  to  be  denied,  that  inflammation  of  the  middle 
ear  does  occasionally  extend  from  the  canal,  through  the  mem- 
brana tympani,  and  not  through  the  Eustachian  tube,  for  we 
have  seen  that  a  draught  of  air  upon  the  side  of  the  head, 
will  produce  acute  aural  catarrh,  and  if  cold  water  enter  the  ear 
through  the  meatus  externus,  and  remain  for  a  considerable 
time,  it  may  also  produce  acute  catarrh  of  the  middle  ear. 

The  use  of  the  nasal  douche  for  the  treatment  of  naso- 
pharyngeal catarrh,  may  also  produce  acute  inflammation  of 
the  ear,  as  I  first  showed  in  an  article  in  the  Archives  of  Oph- 
thalmology and  Otology.*  My  experience  has  since  been  con- 
firmed by  many  other  observers. 

In  the  description  of  the  treatment  of  the  pharynx  and 
nares  in  the  course  of  chronic  aural  inflammation,  the  subject 
of  the  use  of  the  nasal  douche  will  be  more  fully  discussed. 

*  Archives  of  Ophthalmology  and  Otology,  vol.  i.,  No.  1. 


244  TREATMENT    OF  ACUTE   CATARRH. 

Treatment. — The  proper  treatment  of  acute  aural  catarrh 
is  predominantly  an  antiphlogistic  one.  The  disease  is  an 
inflammation  of  the  severest  form,  and  can  only  be  success- 
fully combated  by  such  means  as  local  blood-letting  and 
opium.  A  nervous  pain  in  the  ear,  a  true  otalgia,  is  a  rare 
disease.  In  fifteen  hundred  cases,  I  have  seen  but  one 
such  affection,  and  yet  an  inflammation  of  the  middle  ear  is 
very  often  treated  as  would  be  a  case  of  facial  neuralgia ;  or 
we  might  even  say,  that  the  ordinary  treatment  for  acute 
aural  inflammation  is  pre-eminently  empirical  and  without 
reason.  From  the  time  of  the  ancients  down  to  our  own  day, 
all  kinds  of  decoctions  and  mixtures  have  been  poured  into 
the  ears  to  relieve  ear-ache.  Some  of  these  agents  are  of  a 
negative  or  slight  value ;  many  of  them  are  of  a  positively 
harmful  nature.  To  the  former  class  belong  such  applications 
as  sweet-oil  and  laudanum,  glycerine,  molasses,  and  so  on.  To 
the  latter  class  belong  Harlem  oil,  Cologne  water,  ether,  and  all 
stimulating  applications.  Poultices  are  remedies  often  used  ; 
but  while  they  generally  quiet  pain,  their  application  is  so 
dangerous  to  the  integrity  of  the  drum  membrane,  especially 
if  they  be  used  for  many  hours  in  succession,  that  the  practi- 
tioner will  do  well  to  avoid  them,  unless  other  means  cannot  be 
employed,  or  when  the  latter  prove  ineffectual.  In  some  cases, 
however,  the  urgency  of  the  pain  will  demand  that  poultices 
be  employed.  The  chief  thing  to  be  done  in  this  disease  is 
to  decrease  the  heat,  swelling,  and  vascularity  of  the  parts. 
Applications  of  a  stimulating  nature,  made  to  the  membrana 
tympani,  certainly  cannot  do  this ;  and  mere  emollients,  such 
as  sweet-oil,  have  a  very  transitory  effect. 

I  would  place  local  blood-letting  as  the  chief  and  first 
remedy  in  acute  aural  catarrh.  This  blood-letting  should  be 
performed  by  means  of  leeches  applied  to  the  tragus,  and  not 
to  the  mastoid  process.  Wilde,  and  Von  Troltsch,  have  taught 
the  profession  that  this  is  the  best  point  for  the  application  of 
leeches  in  inflammation  of  the  ears,  and  the  reasons  therefor. 
At  this  point,  the  blood  is  most  easily  drawn  from  the  cavity 
of  the  tympanum — the  vessels  supplying  it,  and  the  drum 
membrane,  inosculating  here.  The  application  of  from  one 
to  six  leeches,  according  to  the  severity  of  the  disease  and 


TEEATMENT  OF  ACUTE  CATAREH.  245 

the  age  of  the  patient,  will  usually  be  sufficient  to  quiet  the 
most  severe  pain  in  the  ear,  and  to  check  the  intensest  form  of 
catarrhal  inflammation.  I  have  seen  almost  magical  effects 
from  their  use.  One  of  the  most  striking  of  the  cases  in  my 
note-book  is  the  following  :  I  was  called  on  a  very  severe  win- 
ter's day  to  see  a  young  gentleman  in  a  neighboring  city,  who 
had  been  suffering  for  two  days  from  acute  pain  referred  to 
the  ear.  I  found  the  symptoms  of  acute  aural  catarrh,  in  a 
reddened  but  intact  drum  membrane,  congested  pharynx,  and 
so  forth.  When  I  entered  the  room  he  seemed  to  be  in  mortal 
agony.  He  said  that  he  had  not  slept  for  forty-eight  hours, 
and  his  anxious  countenance  verified  his  assertion.  I  at  once 
sent  out  for  some  leeches,  and  caused  one  to  be  applied  to 
each  ear,  and  before  they  had  dropped  from  the  tragus  he  was 
asleep,  and  went  rapidly  on  to  perfect  recovery.  Such  cases 
might  be  multiplied,  for  they  are  of  frequent  occurrence  in 
hospital  and  private  practice. 

Leeches  are,  however,  a  troublesome  remedy,  and  in  coun- 
try districts  they  are  not  always  to  be  had.  In  their  absence 
I  place  the  use  of  warm  water  as  next  in  efficiency.  This 
should  be  poured  continuously  into  the  ear,  and  not  used  by 
means  of  a  syringe,  as  I  have  known  patients  to  employ  the 
water  when  told  to  pour  warm  water  into  the  ear.  Clarke's 
aural  douche  (see  illustration  on  page  124)  is  the  best  means 
of  which  I  know  for  applying  warm  water  to  the  ear.  Some- 
times the  warm  water  is  unpleasant,  instead  of  grateful,  to  the 
patient,  and  then  the  vapor  of  water  or  the  smoke  from  a 
cigar  or  pipe  may  be  conducted  into  the  ear.  Children  may 
sometimes  be  relieved  from  a  commencing  attack  of  acute 
aural  catarrh,  by  breathing  into  the  affected  ear  for  a  very  few 
minutes.  If  leeches  cannot  be  had,  and  the  use  of  warm  water 
or  of  steam  does  not  subdue  the  pain,  cups — wet  or  dry — 
applied  around  the  auricle,  are  sometimes  of  use,  or  Hourte- 
loupe's  artificial  leech  may  be  applied. 

Poultices,  as  I  have  said,  are  only  to  be  used  as  a  last 
resort.  Then  they  should  be  made  small  enough  to  be  put  in 
the  canal,  with  only  a  slight  covering  of  the  auricle,  but  a 
denser  one  over  the  mastoid ;  and  their  use  should  be  given  up 
as  soon  as  the  inflammation  has  abated. 


246  PAEACENTESIS  IN  ACUTE  CATAEEH. 

If  the  patient  or  his  friends  are  told  to  apply  the  leeches, 
the  exact  spot  upon  which  they  are  to  be  placed  should  be 
marked  with  ink,  or  they  will  be  put  on  the  lobe,  or  on  the 
neck,  or  in  some  other  position  where  their  use  will  do  no 
good.  I  have  quite  often  found,  that  a  neglect  to  state  just 
where  the  leeches  should  be  applied,  has  caused  all  the  efforts 
to  relieve  pain  to  be  of  no  value. 

Rohland's  styptic  cotton — a  preparation  of  cotton  in  a  solu- 
tion of  alum — prepared  by  Dr.  Rohland  of  this  city,  will  be 
found  a  very  efficient  means  of  arresting  the  hemorrhage 
from  a  leech  bite.  The  bleeding  should,  however,  usually  be 
encouraged,  by  the  use  of  warm  compresses,  for  an  hour  after 
the  leech  has  dropped  from  the  ear. 

Paracentesis  of  the  drum  membrane  is  a  very  efficient 
remedy  at  times,  when  there  is  bulging  of  the  drum-head,  and 
we  see  that  perforation  is  imminent ;  or  even  in  cases  of  pro- 
longed pain  without  bulging  of  the  membrane,  when  the  leeches 
have  been  used  at  too  late  a  period,  or  have  proved  ineffectual. 

Schwartze,  of  Halle,  taught  us  the  value  of  this  means  of 
treatment  in  acute  cases,  and  I  have  found  it  of  great  value. 
I  would  even  pass  a  cataract  needle  through  the  posterior 
portion  of  the  membrana  tympani,  in  any  case,  whether  bulg- 
ing was  seen  or  not,  when  the  use  of  leeches  did  not  markedly 
dimmish  the  severe  pain  within  a  few  hours.  I  have  done  so 
with  striking  effect  in  some  cases.  Yet  leeches  and  warm 
water,  if  promptly  used,  will  usually  check  the  progress  of 
even  the  severest  case.  Very  often,  however,  we  are  not 
called  until  the  disease  has  advanced  so  far  as  to  involve 
every  part  of  the  middle  ear,  when  periostitis  of  the  mastoid 
has  occurred,  and  suppuration  seems  to  be  inevitable. 

Paracentesis  of  the  membrana  tympani  should  be  per- 
formed while  the  head  of  the  patient  is  well  supported,  and  a 
good  light  is  thrown  upon  the  membrane  by  means  of  the  oto- 
scope attached  to  a  forehead  band.  A  needle,  such  as  is 
used  in  the  operation  of  discision  of  a  soft  cataract,  is  the  one 
I  employ.  The  point  of  opening  should  be  determined  by  the 
seat  of  the  greatest  amount  of  bulging,  which  I  have  found  to 
be  in  Shrapnell's  membrane,  and  in  the  posterior  and  inferior 
quadrant  of  the  membrane.    The  operation  causes  so  little  pain, 


TREATMENT  OE  ACUTE  CATARRH.  247 

that  this  element  does  not  enter  into  the  consideration  of  the 
surgeon.  I  have  found  the  light  of  a  candle  about  the  best 
and  most  convenient  source  of  illumination,  when  the  opera- 
tion is  to  be  done  in  a  sick  room,  and  the  patient  is  in  bed. 
An  instrument  with  an  angular  handle  has  some  advantages 
when  the  operation  is  to  be  done  for  chronic  inflammation, 
and  we  desire  to  make  a  larger  opening ;  but  for  acute  cases 
a  thorough  puncture,  through  which  the  blood,  mucus,  or  pus 
can  be  drawn,  is  usually  an  opening  large  enough  to  relieve 
pain.  I  have  more  frequently  performed  the  operation  in 
cases  where  the  severity  of  the  pain  has  passed,  and  yet  I 
have  also  performed  it  with  the  happiest  of  immediate  results 
when  the  patient  was  at  the  height  of  distress. 

If  we  find  on  examination  that  the  mastoid  region  is  red, 
hot,  tender,  and  swelled,  it  will  be  necessary  to  make  an  inci- 
sion through  its  tissues  down  to  the  periosteum ;  but  it  is  only 
very  rarely  that  this  is  the  case  in  acute  aural  catarrh.  Such 
a  state  of  things  is  more  apt  to  be  found  in  subacute  suppura- 
tion, or  as  a  result  of  chronic  suppuration,  under  which  heads 
the  subject  will  be  fully  discussed. 

The  condition  of  the  pharyngeal  mucous  membrane  should 
at  the  same  time  be  attended  to,  by  means  of  gargles  and 
external  applications.  A  saturated  solution  of  chlorate  of  pot- 
ash forms  one  of  the  best  of  applications  to  the  pharynx,  while 
the  neck  may  be  enveloped  in  a  warm-water  poultice. 

The  Eustachian  catheter,  and  Politzer's  method  of  inflat- 
ing the  middle  ear,  should  be  used  as  soon  as  the  acute  symp- 
toms have  subsided,  say  in  twenty-four  hours.  If  employed 
with  gentleness,  there  need  be  no  fear  of  aggravating  the  sub- 
dued inflammation  into  a  relapse. 

The  hearing  should  be  accurately  tested  by  means  of  the 
watch  and  tuning-fork,  in  order  to  see,  after  the  pain  has  sub- 
sided, if  any  impairment  has  occurred.  If  only  one  ear  be 
affected,  careless  patients  will  believe  that  the  hearing  is  per- 
fectly good,  after  the  pain  and  fulness  have  passed  away ;  but 
the  physician  should  be  sure  of  this  for  himself.  In  half- 
treated  acute  catarrh  are  laid  the  foundations  for  that  insidi- 
ous and  obstinate  disease,  chronic  non-suppurative  inflam- 
mation of  the  middle  ear. 


248         TREATMENT  OF  ACUTE  AUEAL  CATARRH. 

While  this  energetic  local  treatment  is  carried  on,  the 
attention  of  the  physician  should  be  turned  to  the  general 
system.  It  will  often  be  necessary  to  give  a  full  dose  of  opium 
or  morphine  at  bed-time.  It  is  somewhat  remarkable,  how- 
ever, that  opium  has  very  little  effect,  when  used  without 
local  depletion,  to  quiet  the  pain  from  aural  inflammation. 
Very  large  doses  will  be  taken  in  vain,  unless  the  local  means 
that  have  been  described  are  also  employed. 

The  patient  should  be  kept  in  the  house,  and  in  a  well- 
warmed  room,  during  the  stage  of  pain  and  fever.  Pediluvia 
and  diaphoretics  are  hardly  necessary  in  case  the  pain  is  once 
subdued.  The  diet  should  be  nourishing.  The  patient  should 
be  enjoined  to  keep  his  skin  in  good  order  by  means  of  fre- 
quent bathing,  in  order  to  prevent  relapses.  The  improper 
habits  of  life,  or  the  exposures  to  cold,  that  have  induced  this 
attack,  should  be  carefully  sought  out,  in  order  that  future 
ones  may  be  avoided. 

The  practitioner  who,  while  treating  a  grave  constitutional 
disease,  finds  this  local  inflammation  breaking  out,  should  by 
no  means  allow  the  severity  or  danger  of  the  constitutional 
symptoms  to  prevent  him  from  the  proper  treatment  of  the 
acute  aural  catarrh.  The  local  and  constitutional  treatment 
can  well  go  on  together ;  while  the  neglect  of  the  ear  at  the 
proper  time  may  lead  to  irreparable  damage  not  only  to  the 
health  and  prosperity  of  the  patient,  but  it  may  destroy  his 
life. 

We  cannot  be  too  much  impressed  with  the  fact  that  a 
neglected  acute  aural  inflammation  may  lead,  through  suppu- 
ration of  the  middle  ear,  with  all  its  consequences  of  caries, 
polypi,  meningitis,  cerebral  abscess,  pyaemia,  to  the  most 
deplorable  results. 

Better  would  it  be  for  a  child  suffering  from  scarlet  fever 
or  measles  to  die  from  the  disease,  than  to  recover  from  the 
constitutional  affection  only  to  succumb,  with  great  misery,  to 
the  effects  of  the  neglected  inflammation  of  the  middle  ear. 
It  is  to  be  hoped  that  the  neglect  of  treatment  of  the  ear  will 
not  prevail  in  the  next  generation  to  the  extent  that  it  does  in 
ours. 

The  practitioner  who  looks  through  the  generally  excellent 


SUB-ACUTE  CATARRH.  249 

works  on  the  diseases  of  children,  will  be  painfully  impressed 
with  the  fact,  that  very  little  attention  is  given  to  the  common 
complications  of  infantile  diseases  with  acute  catarrh  and  sup- 
puration in  the  ear. 

The  course  of  a  case  of  acute  aural  catarrh,  promptly 
treated  in  the  manner  that  has  been  outlined,  usually  ends  in 
complete  recovery,  with  integrity  of  the  structure  and  func- 
tions of  the  ear.  In  less  favorable  cases  suppuration  occurs ; 
but  this  is  usually  tractable,  and  even  then  the  organ  may  be 
restored  to  complete  usefulness.  My  published  cases  show 
that  fifty  of  the  fifty-nine  cases  that  were  recorded  recovered  ; 
while  it  is  probable  that  some  of  the  remaining  nine  did  also, 
although  I  have  no  notes  to  show  this. 

Two  died.  In  one  of  the  cases  there  were  constitutional 
symptoms,  as  I  was  informed,  of  fever,  and  the  acute  aural 
catarrh  may  be  said  to  have  been  incidental  to  typhoid  fever. 
The  other  case  of  death  was  a  case  of  mastoid  disease,  and 
the  patient  died  of  disease  of  the  brain.  It  will  be  referred  to 
in  the  chapter  on  the  affections  of  the  mastoid. 

SUB-ACUTE   CATAKRH  OF  THE  MIDDLE  EAR. 

There  is  a  variety  of  catarrh  of  the  middle  ear  which  is 
very  common  in  young  persons  and  in  children,  that  hardly 
demands  a  separate  chapter  for  its  proper  consideration,  but 
which  differs  in  so  many  respects  from  the  ordinary  type  of 
acute  catarrh,  that  it  seems  to  require  a  more  extended  notice 
than  the  references  that  have  been  made  to  it  in  discussing  the 
latter-named  affection.  I  have  ventured  to  term  this  affection 
sub-acute  catarrh  of  the  middle  ear.  It  has  many  of  the  symp- 
toms of  the  truly  acute  form.  The  absence  of  pain  is  the  chief 
distinguishing  mark  by  which  it  is  separated  from  the  latter 
form.  Some  authors,  judging  from  their  statistics,  have  clas- 
sified it  under  the  head  of  chronic  aural  catarrh.  "While  this 
view  may  not  be  strictly  incorrect — for  the  affection  that  I  am 
about  to  describe,  may  last  for  months,  and  run  into  the 
strictly  chronic  form — it  has,  in  my  opinion,  more  of  the 
characteristics  of  acute  catarrh  in  its  nature,  and  in  its  readi- 
ness to  yield  to  treatment,  than  of  chronic  inflammation. 


250  SUB-ACUTE   CATARRH. 

Symptoms. — The  subjective  symptoms  of  sub-acute  catarrh 
of  the  middle  ear  may  be  stated  as  follows :  It  is  observed 
that  the  patient,  without  suffering  from  pain  in  the  ear,  or  if 
so,  from  pain  that  is  not  long-continued,  is  very  often  so 
hard  of  hearing  as  not  to  hear  ordinary  conversation.  Yery 
little  is  thought  of  this  by  the  friends  of  the  patient,  or  per- 
haps by  the  medical  adviser  ;  but  the  trouble  recurs,  the 
attacks  become  more  frequent,  and  the  period  of  impairment 
of  hearing  more  prolonged,  so  that  school-life  is  seriously 
interrupted.  The  general  health  may,  and  may  not,  be  im- 
paired. I  have  seen  many  such  cases  in  boys  and  girls  in 
excellent  general  health,  as  well  as  in  the  delicate  and 
strumous. 

The  objective  symptoms  are  as  follows :  The  pharynx  is 
usually  in  a  thickened  or  granular  condition,  the  normal  secre- 
tion is  excessive,  and  it  may  be  changed  in  quality,  and  be 
decidedly  muco-purulent.  The  tonsils  may  or  may  not  be 
hypertrophied.  The  membrana  tympani  has  lost  its  normal 
neutral  gray  color,  and  is  of  a  pinkish  hue.  The  vessels  are  not 
usually  to  be  traced  upon  any  part  of  it.  It  may  be  exceed- 
ingly brilliant.  The  light  spot  is  usually  absent,  or  is  smaller 
than  usual ;  a  fact  which  shows  that  the  drum-head  is  sunken  in- 
ward. The  experiments  of  Magnus,  which  have  been  described 
in  the  tenth  chapter,  show  that  any  excessive  pressure  which 
pushes  the  drum-head  inwards  lessens,  or  if  the  pressure  be 
great  enough,  obliterates,  the  light  spot.  The  hearing  as 
tested  by  the  watch  is  found  to  be  very  much  impaired,  and 
only  such  conversation  as  is  addressed  to  the  patient,  with 
his  face  towards  the  speaker,  is  heard. 

This  impairment  of  hearing  is  very  often  attributed  to 
"absent  mindedness"  by  parents,  and  to  "stupidity"  by 
teachers.  Children  are  not  usually  absent-minded,  and  when 
they  are  stupid,  there  is  always  a  cause,  which  should  be 
traced  out,  and  the  poor  child  not  treated  as  if  it  were  respon- 
sible for  the  disease  that  has  rendered  it  so.  Again  and 
again  will  the  practitioner  find  that  he  is  obliged  to  correct 
the  false  ideas  of  parents  and  teachers,  who  believe  that  chil- 
dren do  not  always  prefer  to  hear,  if  they  can.  Malingering 
as  to  deafness,  is  a  deception  which  children  rarely  understand, 


SUB-ACUTE  CATAREH.  251 

and  which  they  can  never  successfully  maintain.  A  child  that 
does  not  habitually  answer  readily  when  addressed,  should 
be  at  once  carefully  examined  as  to  its  hearing  power,  and 
not  scolded  for  absent-mindedness. 

Treatment. — It  is  apt  to  be  the  case,  that  proper  hygienic 
rules  have  not  been  observed  in  the  management  of  such  young 
patients.  They  have  been  allowed  to  eat  and  drink  food  impro- 
per for  growing  persons ;  for  example,  tea  and  coffee,  pastry  and 
so  forth,  to  the  greater  or  less  exclusion  of  simpler  and  more 
nutritious  substances,  and  thus  a  capricious  state  of  the  appe- 
tite has  been  induced.  In  the  case  of  boys,  frequent  and  pro- 
longed bathing  or  swimming,  of  which  ducking  the  head  under 
water  forms  the  chief  part,  is  sometimes  found  to  cause  or 
increase  the  impairment  of  hearing.  The  regulation  of  the 
diet  of  such  patients,  the  wearing  of  flannel  next  the  skin,  the 
abstaining  from  any  habits  which  may  be  recognized  as  pre- 
disposing to  inflammation  of  delicate  structures,  building  up 
of  the  system  by  a  proper  therapeutic  course,  such  as  the 
exhibition  of  cod-liver  oil  and  iron,  with  proper  attention 
by  the  use  of  gargles  to  the  mucous  membrane  of  the 
pharynx,  will  perhaps  in  time  allow  Nature  to  relieve  these 
cases ;  but  the  impairment  of  hearing,  which  is  the  most 
striking  and  most  troublesome  symptom,  will  be  the  last  one 
relieved,  and  it  may  not  be  relieved  at  all,  and  the  patient 
grow,  up  to  be  permanently  hard  of  hearing.  "We  have  at 
our  hands,  however,  in  Politzer's  mode  of  inflating  the  ears — ■ 
a  method  of  treatment  that  has  been  fully  described  on  page 
98 — a  means  of  instantly  improving  the  hearing,  and  thus 
of  removing  the  most  embarrassing  symptom  in  an  instant. 

The  wonder  and  joy  depicted  on  a  little  patient's  face  when 
the  world  of  sound  opens  to  him  again,  after  the  air  has  once 
entered  the  Eustachian  tubes  and  tympanic  cavities,  is  some- 
thing very  pleasant  to  see.  In  the  absence  of  the  air-bag,  a 
bit  of  india-rubber  tubing  inserted  in  one  nostril,  the  other 
being  closed,  through  which  air  is  blown  from  the  lungs  of  the 
surgeon,  will  do  very  well.  Indeed,  where  the  subjects  are 
very  young  I  prefer  this  method;  which  is  Mr.  James  Hin- 
ton's  adaptation  of  Politzer's  principle. 


252  SUB-ACUTE  CATARRH". 

The  pathological  changes  in  these  cases,  which  cause  the 
impairment  of  hearing,  are  probably  in  some  cases  simply 
plugging  of  the  f aucial  orifice  of  the  Eustachian  tube,  in 
others  of  the  caliber  of  the  tube  and  the  tympanic  cavity  by 
mucus.  Structural  changes,  such  as  thickening  of  the  mucous 
membrane,  bands  of  adhesions,  have  not  occurred.  Hence  I 
would  not  class  these  cases  among  those  of  chronic  catarrhal 
inflammation. 

I  append  three  cases,  two  of  which  have  been  before  pub- 
lished ;*  but  I  have  been  able  to  follow  them  up,  and  note 
that  the  recovery  was  perfect.  I  again  publish  them,  with  an 
additional  one  of  the  same  character.  The  cases  are  very 
common,  and  it  is  not  therefore  for  their  rarity  that  they  are 
inserted,  but  that  they  may  perhaps  teach  how  much  may  be 
done  to  instantly  relieve  this  form  of  disease.  The  practitioner 
who  ignores  the  ear  will  certainly  pass  by,  among  these  cases, 
many  which,  if  properly  examined  and  treated,  would  add  very 
much  to  his  reputation,  and' increase  his  power  of  doing  good. 

CASES. 

Case  I.— F.  S.  B.,  aged  16,  K  Y.,  Sept.  1, 1865.  Has  been  deaf  at  times  for 
a  number  of  years,  and  for  the  last  summer  persistently  so.  His  general  con- 
dition is  fair ;  is  well  developed.  The  tonsils  had  been  so  much  hypertrophied  as 
to  impede  respiration ;  but  they  were  removed  previous  to  his  coming  under 
my  observation.  The  pharynx  secretes  excessively,  as  well  as  the  nasal 
mucous  membrane.  There  are  numerous  granulations  scattered  over  the  pha- 
rynx. The  membrane  tympani  are  pinkish,  brilliant  in  appearance.  The 
light  spot  is  elongated.  The  watch  is  heard  about  six  inches  from  each 
auricle. 

Politzer's  method  was  practised  three  or  four  times,  when  the  hearing  dis- 
tance extended  to  sixteen  inches  on  the  right  side,  and  ten  on  the  left.  A  gar- 
gle containing  iodine  and  brandy  was  ordered  to  be  used  twice  a  day.  He  was 
also  to  practise  Politzer's  method  twice  a  week,  in  connection  with  the  iodine 
inhaler.  The  patient  continued  to  improve,  and  at  the  present  writing,  April 
20,  1866,  the  treatment  has  been  abandoned,  the  hearing  power  being  nearly, 
if  not  quite  normal.  The  patient  goes  to  school  every  day.  He  was  seen  by 
me  for  some  weeks  once  a  week,  while  his  father,  who  is  a  distinguished  phy- 
sician of  this  city,  carried  out  the  treatment  at  home,  which  consisted  in  the 
use  of  the  gargle,  inflating  the  middle  ear  by  Politzer's  method  once  in  three 
or  four  days,  with  attention  to  the  general  health.  1872.  The  patient  is 
now  a  young  man  in  college,  and  has  no  trouble  on  account  of  his  hearing. 

*  American  Journal  of  the  Medical  Sciences,  vol.  vii.,  p.  64. 


CASES  OP   SUB-ACUTE  CATARRH.  253 

Case  II. — Girl,  aged  16,  at  Eye  and  Ear  Clinic  in  University  Medical  Col- 
lege, March  28,  1866.  Has  not  heard  ordinary  conversation  for  years,  and  has 
been  very  much  embarrassed  in  swallowing  and  breathing,  on  account  of 
enlarged  tonsils  ;  general  condition  is  fair ;  the  voice  is  extremely  nasal ;  only 
hears  when  addressed  in  a  loud  tone  of  voice ;  the  watch  is  heard  two  inches 
on  the  right  side,  one  inch  on  the  left ;  membranse  tympani  present  nothing 
striking  in  appearance,  except  that  they  are  quite  brilliant ;  the  tonsils  are 
excessively  hypertrophied.  The  use  of  Politzer's  method  immediately  improved 
the  hearing  somewhat,  which  improvement  lasted,  according  to  the  patient's 
statement,  about  a  day.  When  next  seen,  the  tonsils  were  excised  with  the 
forceps  and  scissors,  a  long  outgrowth  being  dragged  down  from  behind  the 
soft  palate  on  the  right  side,  which  must  have  pressed  upon  the  orifice  of  the 
Eustachian  tube,  and  then  the  iodized  air  was  driven  into  the  tube.  The 
hearing  distance  became  two  feet  on  the  right  side,  and  about  six  inches  on 
the  left.  An  iodine  gargle  was  ordered,  with  cod-liver  oil,  a  half  tablespoonful 
to  be  taken  three  times  a  day.  The  patient  is  now  under  treatment,  and  still 
(April  26,  1866)  continues  to  improve,  hearing  very  well,  with  no  trouble  in 
respiration.  1872.  I  have  seen  this  patient  several  times  since,  on  account  of 
naso-pharyngeal  catarrh,  and  her  recovery  of  hearing  proves  to  be  permanent. 

Case  III. — Master (sent  to  me  by  Prof.  Fordyce  Barker,  Jan.  21, 1873), 

set.  14.  This  boy  has  had  "  a  cold,"  and  has  been  very  hard  of  hearing  for 
some  weeks.  He  is  in  excellent  general  health.  The  membranae  tympani  pre- 
sent nothing  particularly  abnormal.  The  pharynx  and  nostrils  are  secreting 
excessively.  Hearing  distance — right  ear,  -438- ;  left  ear,  the  watch  is  only 
heard  when  laid  on  the  auricle.  He  was  seen  every  other  day  for  three 
weeks,  when  the  Eustachian  catheter  and  Politzer's  method  were  used,  while 
a  gargle  of  chlorate  of  potash  was  employed  at  home.  At  the  first  sitting 
his  hearing  distance  was  brought  up  to  ■£§  E.  E.,  -4a8-  left,  so  that  conversation 
was  heard  with  much  more  ease,  and  when  his  hearing  power  became  f  §  on 
each  side,  and  was  still  improving,  he  was  allowed  to  return  to  his  school. 

The  use  of  the  catheter  when  the  patients  will  submit  to  it, 
and  nearly  all  except  infants  will  do  so,  causes  the  action  of 
Politzer's  method  to  be  more  powerful.  It  probably  excites 
the  muscles  of  the  tube  to  more  vigorous  contraction.  When 
children  are  too  young  to  swallow  on  the  signal,  we  may  still 
employ  Politzer's  method,  by  putting  the  tube  in  one  nostril, 
closing  the  other  with  the  finger,  and  rapidly  forcing  in  the  air 
in  spite  of  the  child's  screams,  which  are  not  those  of  pain. 
During  the  swallowing  motion  that  the  little  one  makes,  some 
air  will  enter  the  tube.  It  is  highly  probable  that  infants 
sometimes  suffer  from  sub-acute  catarrh,  which  if  not  relieved 
by  local  treatment  passes  on  to  a  chronic  process,  which 
end  in    deaf  -  muteism.     Where  any  doubt  exists,  the  little 


254  OTITIS   MEDIA   HEMOEEHAGICA. 

patient  should  have  the  benefit  of  it,  by  the  use  of  Politzer's 
method,  "which  can  do  no  harm,  and  may  do  a  vast  deal  of 
good.  The  existence  of  a  nasal  catarrh  in  an  infant,  should 
be  carefully  considered  by  the  attending  physician,  lest  it 
result  in  one  of  the  tympanic  cavity,  and  there  cause  changes 
which  must  leave  permanent  impairment  of  hearing. 

OTITIS  MEDIA  HEMORRHAGICA. 

I  have  seen  and  reported  *  two  cases  of  acute  aural  catarrh 
which  had  an  unusual  course  and  termination — that  is  to 
say,  the  course  was  very  acute  and  terminated  rapidly  in 
perforation  of  the  membrana  tympani  without  suppuration, 
but  with  quite  an  abundant  hemorrhage  through  the  drum- 
head. It  is  well  established  that  hemorrhage  into  the  mid- 
dle ear  may  occur  in  the  course  of  kidney  disease,  just  as 
from  the  vessels  of  the  retina ;  but  the  two  cases  which  I 
am  about  to  describe  certainly  do  not  come  under  the  classi- 
fication of  hemorrhage  from  blood-vessels  made  atheroma- 
tous by  renal  disease.  They  are,  I  think,  to  be  considered 
as  cases  of  acute  inflammation  of  the  lining  membrane  of 
the  middle  ear,  in  which  the  morbid  process  has  an  unusually 
rapid  and  violent  course,  so  that  not  merely  an  exudation 
through  the  walls  of  the  vessels,  but  an  actual  breaking 
down  of  the  walls  themselves,  occurs ;  there  is  then  such  an 
accumulation  of  the  blood  in  the  cavity  of  the  tympanum 
that  rupture  of  the  drum-head  almost  necessarily  follows. 
It  has  been  often  observed  that  in  many  cases  of  paracen- 
tesis of  the  membrane,  for  the  relief  of  inflammation  of  the 
lining  membrane  of  the  drum  cavity,  blood  is  the  only  pro- 
duct that  escapes.  I  think  these  cases  are  analogous  to  those 
which  I  am  about  to  record,  and  that  they  serve  to  explain 
them. 

Case  I. — The  first  case  that  directed  my  attention  to  hemorrhage  through 
the  membrana  tympani,  as  a  consequence  of  acute  inflammation  of  the  middle 
ear,  was  that  of  a  young  lady,  of  rather  delicate  organization,  who  was  under  the 
care  of  Drs.  Agnew  and  Loring.    The  case  was  seen  in  consultation  with  the 

*  Transactions  of  the  American  Otological  Society,  1872. 


CASES  OF  OTITIS  HEMORRHAGICA.  255 

latter-named  gentleman,  who  gave  me  the  history.  The  patient  was  deaf 
from  what  seemed  to  be  hypertrophy  of  the  membrane  lining  the  drum  cavity  ; 
the  membrana  tympani  was  thickened,  sunken,  and  immovable ;  she  was 
treated  in  the  usual  manner,  i.  e.,  the  catheter  and  Politzer's  method  were 
employed,  and  the  attempt  made  by  them  to  force  the  drum-head  outward. 
On  the  day  or  day  before  I  saw  the  patient,  and  about  twenty-four  hours  after 
the  catheter  and  Politzer's  method  were  used,  she  was  seized  with  violent  pain 
referred  to  the  deptb  of  the  ear  ;  to  relieve  this,  paregoric  was  dropped  into  the 
ear.  Dr.  Loring  and  I  saw  the  patient  in  the  evening ;  the  pain  had  then 
somewhat  abated.  On  examination,  I  found,  after  carefully  removing  the 
fluid  that  had  been  dropped  in,  that  the  membrana  tympani  was  ruptured,  and 
that  blood  was  issuing  from  the  pulsating  opening.  The  patient  recovered 
after  an  erysipelatous  inflammation  of  the  auditory  canal  and  side  of  the  face. 
I  did  not  see  her  again,  but  Dr.  Agnew  examined  the  membrane  in  a  few  days, 
and  could  find  no  rupture,  and  no  trace  of  it. 

I  might,  perhaps,  be  slightly  in  doubt  as  to  the  occurrence  of  a  rupture  and 
hemorrhage  from  the  membrane  in  this  case,  had  I  not  seen  one  subsequently 
which  was  very  similar,  and  where,  as  in  this  case,  no  suppuration  occurred 
after  the  rupture,  and  consequently  no  scar  remained.  The  presence  of  the 
paregoric  rendered  it  somewhat  difficult  to  determine  whether  the  fluid  in  the 
rupture  was  blood  or  not ;  but  I  took  this  fully  into  consideration,  and  deter- 
mined that  it  was. 

Case  II. — This  occurred  in  a  gentleman  in  good  health,  of  forty-seven 
years  of  age.  He  smoked  excessively,  but  in  other  respects  his  habits  were 
good.  He  had  chronic  pharyngeal  catarrh,  but  it  troubled  him  very  little. 
He  did  not  remember  that  he  had  ever  had  ear-ache  as  a  child  or  adult.  I  saw 
him  on  November  7,  1871.  His  history  was  as  follows :  About  ten  o'clock 
to-day,  he  suddenly  experienced  a  severe  pain  in  his  right  ear.  The  pain  was 
so  acute  that  the  patient  was  obliged  to  leave  his  business  and  go  home.  The 
treatment  consisted  in  the  instillation  of  sweet  oil  and  tincture  of  opium. 
There  was  no  relief,  however,  until  about  six  P.  M.,  when  "  a  loud  report 
occurred  in  his  head,"  and  quite  a  free  hemorrhage  occurred.  The  patient 
thought  more  than  a  teaspoonful  of  blood  escaped.  I  saw  him  a  few  moments 
after  the  hemorrhage  had  occurred.  The  pain  had  entirely  subsided ;  the 
membrana  tympani  was  perforated  in  the  anterior  and  inferior  quadrant,  and 
a  small  quantity  of  dark-colored  blood  was  about  and  in  the  opening,  while 
the  membrane  was  pulsating  as  in  the  former  case,  or  rather  the  blood  column 
was  pulsating  in  the  cavity  of  the  tympanum.  This  patient  fully  recovered 
without  any  suppuration  whatever.  The  opening  healed,  and  the  hearing, 
which  was  reduced  to  such  an  amount  as  to  be  expressed  by  the  fraction  -}§, 
was  restored  to  a  normal  standard.  The  treatment  consisted  in  the  careful 
use  of  an  injection  of  tepid  water,  just  after  the  occurrence  of  the  rupture,  with 
the  subsequent  use  of  the  Eustachian  catheter,  through  which  air  was  intro- 
duced, and  Politzer's  method  of  inflating  the  drum-head. 

The  history  of  these  two  cases,  as  well  as  of  those  cases 
of  paracentesis  of  the  membrana  tympani  where  blood  only 


256  AUEAL  HEMOEEHAGE  IN  BBIGHT'S  DISEASE. 

escaped,  indicates  that  otitis  media  hemorrhagica  is  a  much 
more  tractable  form  of  middle-ear  inflammation  than  true 
catarrhal,  or  suppurative  inflammation.  They  serve  to 
strengthen  the  indications  for  an  early  perforation  of  the 
drum-head  when  accumulations  occur  in  the  tympanic  cavity. 

AURAL  HEMORRHAGE  IN  THE  COURSE  OF  BRIGHT'S  DISEASE. 

There  will,  perhaps,  be  no  better  opportunity  than  the  pre- 
sent of  alluding  to  those  hemorrhages  from  the  tympanic  ves- 
sels that  occasionally  occur  in  Bright's  disease.  Schwartze 
reported  such  a  case*  in  1869. 

The  patient  was  a  non-commissioned  officer,  of  twenty-five  years  of  age, 
who  suffered  from  albuminuria,  with  retinal  hemorrhages.  There  was  also 
enlargement  of  the  liver  and  spleen,  and  infiltration  of  the  lungs.  On  the  16th 
January,  1868,  he  suddenly  complained  of  pain  in  his  right  ear,  which  had  been 
previously  sound.  When  Dr.  Schwartze  saw  the  patient  some  hours  after, 
the  membrana  tympani  was  of  a  bluish-red  color  and  devoid  of  concavity. 
Some  leeches  were  applied,  but  they  did  very  little  good.  The  next  day  the 
membrane  was  of  a  dark-red  color,  so  that  an  extravasation  of  blood  into  the 
cavity  of  the  tympanum  was  plainly  evident.  On  the  19th  there  was  an 
abundant  serous  discharge,  and  when  the  ear  was  cleansed  by  a  syringe,  a 
small  blood  coagulum  was  removed.  Anteriorly  and  below  there  was  a  perfo- 
ration in  the  membrana  tympani  about  as  large  as  the  head  of  a  pin.  In  the 
afternoon  a  whitish  mass  came  out  of  the  ear,  in  the  water  that  was  instilled 
every  ten  minutes.  This  mass,  which  looked  like  a  fibrous  coagulum,  was  one 
and  a  half  inches  long,  and  two  lines  broad,  and  one-half  a  line  thick.  On  the 
20th  another  similar  mass  came  out,  and  on  the  22d  the  patient  died.  The 
discharge  from  the  ear  had  then  become  purulent. 

The  microscopic  examination  of  the  mass  removed,  when  it  was  not  quite 
fresh,  showed  an  extremely  fine  granular  material,  mixed  with  numerous 
scales  of  epithelium.  The  post-mortem  examination  was  made  on  the  23d  Jan- 
uary. There  was  great  hypertrophy  and  dilatation  of  the  left  ventricle.  Both 
kidneys  were  atrophied.  The  lungs  and  spleen  enlarged.  Pneumonia  of  both 
lungs.     Retinitis  apoplectica,  with  retinal  detachment  on  both  sides. 

Ears. — Hemorrhagic  inflammation  of  the  membrane  lining  the  right  cavity 
of  the  tympanum  ;  cavity  of  the  tympanum  filled  with  bloody  purulent  fluid. 
Membrana  tympani  greatly  reddened  and  swelled,  covered  by  a  thin  layer  of 
pus,  and  perforated  as  before  stated.  The  mucous  membrane  of  the  Eustachian 
tube  was  also  injected,  but  not  so  markedly  as  the  tympanic  cavity.  No  affec- 
tion of  the  labyrinth. 

In  the  left  ear,  of  which  the  patient  did  not  complain  during  life,  the  cav- 

*  Archiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  12. 


AURAL  HEMORRHAGE  IN  BRIGHT'S  DISEASE.  257 

ity  of  the  tympanum  was  also  filled  with  a  Moody  serous  fluid  ;  but  there  was 
no  inflammation  of  the  lining  membrane.  There  were  small  ecchymoses  on  the 
mucous  membrane  of  the  naso-pharyngeal  space.  The  mucous  membrane  of 
the  tube  was  injected,  and  mostly  so  at  the  faucial  orifice  of  the  tube. 

In  the  same  year  that  Schwartze  published  his  case,  my 
friend  Dr.  Gouverneur  M.  Smith  read  a  paper  before  the 
Academy  of  Medicine,*  in  which  he  called  attention  to  the 
fact  that  impairment  of  hearing  was  at  times  one  of  the  symp- 
toms of  Bright's  disease,  and  a  symptom  that  could  not  be 
explained  by  referring  it  to  uraemia.  The  author  once  treated 
a  case  of  obstinate  suppuration  in  the  middle  ear,  in  a  man 
of  61  years  of  age,  who,  although  suffering  from  Bright's  dis- 
ease, of  which  he  died,  complained  chiefly  of  neuralgic  pains 
referred  to  his  suppurating  ear,  for  three  or  four  months  prior 
to  his  death.  I  have  now  no  doubt  that  the  renal  disease,  by 
its  effect  upon  the  tympanic  vessels,  was  the  cause  of  the 
acute  suppuration  in  the  ear,  and  that  if  I  had  seen  the  case 
when  the  rupture  of  the  drum-head  occurred,  that  I  would 
have  found  it  hemorrhagic  in  its  nature. 

The  subject  is  clearly  of  enough  importance,  to  lead  us  to 
be  on  our  guard  for  renal  disease  in  cases  of  hemorrhage  into 
the  tympanic  cavity,  or  even  in  cases  of  severe  pain  in  the 
ear,  occurring  in  persons  who  seem  to  have  any  disposition  to 
kidney  disease. 

*  On  the  Etiology  of  Bright's  Disease,  with  Remarks  on  the  Prophylaxis. 
Transactions  of  the  New  York  Academy  of  Medicine,  vol.  iii. 

Note. — Since  the  publication  of  the  author's  cases  of  Otitis  Media  Hemor- 
rhagica, Dr  Mathewson  of  Brooklyn,  and  Dr.  Hackley  of  New  York,  have  also 
observed  and  reported  at  a  meeting  of  the  New  York  Ophthalmological 
Society,  cases  of  acute  inflammation  of  the  middle  ear,  in  which  hemorrhage 
occurred  through  the  membrana  tympani  before  any  pus  appeared.  Their 
course  was  quite  similar  to  that  of  those  related  on  pages  255  and  256.  Dr. 
Hackley 's  case  occurred  in  a  young  woman  who  had  just  passed  through  the 
menstrual  period,  and  the  menses  reappeared  after  the  aural  hemorrhage 
ceased. 

17 


CHAPTER    XII. 

CHRONIC  NON-SUPPURATIVE   INFLAMMATION  OF  THE 
MIDDLE    EAR. 

Both  in  the  ranks  of  the  laitj  and  the  profession,  the 
treatment  of  aural  diseases  has  of  old  been  stigmatized  as 
unsuccessful  and  unsatisfactory.  Carefully  made  observations 
of  the  results  of  rational  and  scientific  practice,  in  a  large 
number  of  cases,  have  shown  that  this  reproach  can  only  with 
justice,  if  at  all,  be  applied  to  two  classes  of  the  affections  of 
the  ear.  Nearly  all  the  others  are  singularly  tractable  when 
their  course  is  properly  regulated.  By  these  two  classes,  I 
mean  chronic  non-suppurative  inflammation  of  the  middle  ear, 
and  the  affections  of  the  labyrinth,  or  internal  ear.  In  recent 
times  the  generic  term,  chronic  catarrhal  inflammation  of  the 
middle  ear,  is  usually  employed  to  designate  the  former 
variety  of  disease. 

I  shall  soon  find  fault  with  the  indiscriminate  use  of  this 
name,  but  for  the  present  we  may  allow  it  to  stand,  as  giving 
a  pretty  clear  idea  of  the  affections  arranged  under  it.  Statis- 
tics show  that,  of  every  thousand  cases  of  aural  disease,  that 
present  themselves  in  private  practice,  a  little  more  than  one- 
half  are  chronic  non-suppurative  inflammations  of  the  middle 
ear.*  The  disease  is  called  chronic  because,  when  it  first 
comes  to  professional  notice,  it  has  usually  already  existed  for 
months  and  years,  and  because,  if  unchecked,  it  advances  with 
destructive  progress  as  long  as  life  lasts.  Although  the  dis- 
ease often  does  its  work  of  impairing  or  destroying  the  func- 
tion of  hearing,  with  but  few  of  the  subjective  evidences  of 

*  New  York  Medical  Journal,  August,  1869.    Transactions  Medical  Society 
State  of  New  York,  1871. 


CHK0NIC   NON-SUPPUEATIVE   INFLAMMATION.  259 

what  is  called  inflammation — there  may  be  no  heat,  redness,  or 
pain — we  find  many  of  the  other  marks  of  diseased  action,  in 
swelling,  thickening,  adhesions,  which  entitle  it  to  be  placed 
under  this  head.  It  has  also  been  called  a  catarrhal  inflam- 
mation, because  the  cavity,  air-chamber,  and  tube,  which  form 
its  seat,  are  lined  by  mucous  membrane.  We  say  middle  ear, 
because  these  parts  form  the  anatomical  centre  of  the  organ 
of  hearing.  It  is  the  same  disease  which  Sir  William  Wilde 
understood,  but  which,  as  it  seems  to  me,  he  inappropriately 
called  chronic  myringitis,  or  inflammation  of  the  drum-head. 
But  the  drum-head  is  only  one  of  other  parts  that  is  affected 
in  this  disease,  and  may,  perhaps,  be  scarcely  at  all  injured, 
while  the  most  important  changes  in  structure  and  function 
have  occurred  in  other  parts  of  the  middle  ear.  In  common 
speech — and  I  do  not  mean  by  this,  among  the  laity,  but  in 
the  profession — many  of  the  forms  of  chronic  catarrh  of  the 
middle  ear  have  been,  from  time  immemorial,  classified  as 
nervous.  The  great  author  whoni  I  have  just  quoted,  did 
much  to  combat  this  error — an  error  which  not  only  kept 
back  the  growth  of  the  science  of  otology,  because  it  retarded 
the  conception  of  a  successful  plan  of  treatment,  but  which 
also  assisted  to  deepen  the  reproach  which  for  centuries  has 
rendered  aural  disease  the  bete  noir  of  medical  practice. 

The  reason  for  this  classification  of  these  affections  as  ner- 
vous is  found  in  the  fact  that  the  poor  means  of  diagnosis, 
which  were  in  the  hands  of  the  profession  until  a  few  years 
since,  the  absence  of  a  simple  otoscope,  and  the  want  of 
knowledge  of  the  value  of  the  Eustachian  catheter,  and  the 
tuning-fork,  did  not  allow  of  the  appreciation  of  the  delicate 
changes  which  make  up  what  the  Germans  call  the  "  Kranh- 
lieitsbild" — the  picture  of  the  disease.  There  was  another 
reason  in  the  fact  that  the  poor,  distressed  patient,  having 
gone  in  vain  to  his  usual  consolers,  if  not  curers — the  regular 
practitioners — often  resorted  to  the  charlatan.  Under  his 
wonderful  but  distressing  treatment,  added  to  the  trial  of  the 
horrible  tinnitus  aurium,  and  impairment  of  hearing,  he  became 
so  utterly  worn  out  and  so  distrustful  of  each  new  adviser, 
that  the  so-called  nervousness  was  very  apparent. 

The  common  idea  of  nervous  deafness  is  that  it  occurs 


260 


CHEONIC  NON-SUPPUBATTVE  INFLAMMATION. 


chiefly  amoDg  the  weak  and  sensitive  ;  but  this  notion  has  no 
basis  in  pathology — so-called  nervous  people  are  not  apt  to 
be  deaf,  nor  does  their  sensitive  or  nervous  organism  have 
much  effect  upon  their  hearing  power,  unless  it  is  already  im- 
paired from  an  inflammatory  cause.* 

As  yet  this  class  of  cases  comes  as  a  rule  to  the  notice  of 
the  practitioner  of  modern  otology  only  when  the  disease  is 
far  advanced. 

The  following  table  shows  this  : 

Cases  of  Chronic  Nonsuppurative  Inflammation. — Whole  number,  525. 

No.  of  cases  of  80  years'  standing        ....  1 

"           over  40  years'  standing    ....  6 

over  20    "            "            ....  40 

"          between  10  and  20  years'  standing          .  133 

5  and  10             "              .        .  141 

3  and    5              "              .         .  75 

1  and    3              "             .  74 

"           one  year 42 

"          less  than  one  year 13 


Whole  number 


525 


These  are  the  cases  of  this  disease  that  I  have  recorded, 
in  private  practice.  It  will  be  seen  that  by  far  the  larger 
number,  more  than  fifty  per  centum,  had  observed  some  loss 
of  function  for  more  than  five  years,  while  about  eight  per 
cent,  had  been  affected  for  more  than  twenty  years. 

Every  person  has,  so  to  speak,  a  superfluous  amount  of 
hearing,  which  he  may  lose  before  his  hearing  is  sufficiently 
impaired  to  annoy  him  in  the  common  affairs  of  life.  People 
who  spend  many  hours  of  the  day  in  noisy  places,  such  as 
boiler-shops,  on  board  steamships,  in  the  stock-board  of  Wall 
Street,  as  I  have  seen  by  frequent  examples,  may  lose  very 
much  of  their  hearing  power  before  they  are  at  all  aware  of  it. 
Then,  again,  the  lower  classes,  who  labor  hard  all  day  in  the 
open  air  with  their  fellows,  and  who  live  at  night  in  small  and 
noisy  rooms,  where  the  demands  upon  the  hearing  power 
are  very  slight,  hardly  consider  its  impairment  as  a  loss  of 
function. 

These  causes  have  conspired,  with  the  general  ignorance  of 
the  pathology  and  treatment  of  non-suppurative  aural  disease, 


NOMENCLATUKE.  2G1 

to  render  the  results  of  treatment  unsatisfactory,  as  well  as  to 
cause  patients  to  consult  a  physician  at  a  very  late  stage  of 
their  trouble.  Be  all  this  as  it  may,  we  now  have  tolerably 
accurate  means  of  diagnosticating,  and  fairly  successful  means 
of  treating  those  affections,  and  it  is  in  the  light  of  these 
recent  advances  that  we  are  now  able  to  speak. 

First,  as  to  the  nomenclature.  I  have  never  been  fully 
satisfied  with  the  nomenclature  of  Von  Troltsch,  vast  improve- 
ment as  it  was  on  those  classifications  which  had  preceded  it. 
Some  of  them  were  crude,  others  fanciful  and  altogether  too 
refined.  Von  Troltsch  classified  all  non-suppurative  disease 
as  catarrhal,  and  then  separated  those  in  which  the  catarrhal 
symptom — excess  of  secretion — was  not  very  marked,  by  plac- 
ing them  under  the  head  of  sclerosis  or  hardening  or  rigidity 
of  the  mucous  membrane.  After  looking  at  many  ears,  in 
which  there  was  no  trace,  either  in  the  pharynx,  Eustachian 
tube,  or  cavity  of  the  tympanum,  of  an  excess  of  secretion 
from  the  mucous  membrane,  but  in  which  there  were  marked 
changes  in  the  way  of  increase,  hypertrophy  or  proliferation 
of  tissue,  and  in  others  where  the  catarrhal  symptoms  were 
very  much  in  the  background,  although  they  existed,  I  felt  that 
aural  catarrh  was  a  meagre  and  incorrect  name  with  which  to 
describe  such  a  state  of  things.  The  very  name  "  catarrh,"  as 
applied  to  a  sunken  drum-head,  immovable  chain  of  bones, 
dry  pharynx,  easily  permeable  Eustachian  tubes,  is  repugnant 
to  all  our  notions  of  scientific  nomenclature.  "Whatever  may 
have  been  the  origin  or  exciting  cause  of  such  cases,  they 
cannot  be  called  catarrhal,  when  their  examination  shows  such 
a  state  of  things  as  this. 

Gruber  has  made  a  division  in  his  text-book,  and  describes 
an  otitis  media  hypertrophica-,  or  plastic  inflammation ;  but  I 
think  his  own  description  of  the  pathology  of  the  disease 
shows  that  he  is  discussing  not  what  has  hitherto  been  com- 
prehended under  the  head  of  sclerosis,  but  an  extension  of  a 
suppurative  process,  such  as  causes  the  formation  of  granula- 
tions or  polypi. 

The  nomenclature  of  the  author  is  founded  on  his  own 
clinical  experience,  and  upon  the  reports  of  the  pathology  of 
this  class  of  cases  that  have  been  made  by  Toynbee  and  others. 


262  CATAKEHAL  AND  PEOLIFEEOUS  INFT.ATVnVLATIOK 

Chronic  non-suppurative  inflammations  of  the  middle  ear 
may  be  divided  into  two  great  classes, 

Catarrhal, 
Proliferous. 

I  choose  the  translation  of  the  German  word  Wucherung 
as  furnishing  the  best  adjective  to  describe  the  changes  in  the 
middle  ear,  of  which  I  am  to  speak  ;  and  in  what  I  have  to  say 
I  shall  attempt  to  be  guided  by  these  divisions. 

Some  authors  and  practitioners  would  admit  another  clas- 
sification, based  upon  the  parts  involved,  and  speak  of  chronic 
myringitis,  or  chronic  inflammation  of  the  membrana  tympani, 
and  of  chronic  catarrh  of  the  Eustachian  tube.  Whatever  we 
may  believe  of  acute  inflammation  of  these  parts,  I  can  scarcely 
accept  the  idea  of  one  that  has  existed  for  any  considerable 
space  of  time  without  involving  either  the  cavity  of  the  tym- 
panum or  the  mastoid  cells,  or  both.  The  nomenclature,  tubal 
catarrh,  also  leads,  as  I  believe,  to  incorrect  notions  as  to  the 
therapeutic  value  of  the  Eustachian  catheter,  and  of  Politzer's 
method  of  inflating  the  drum  cavity.  These  methods  of  treat- 
ment are  useful,  not  so  much  for  what  they  do  to  the  tube, 
but  for  their  effect  upon  the  cavities  into  which  it  opens. 
When  air-bubbles  are  crackling  in  the  cavity  of  the  tym- 
panum, as  in  catarrhal  inflammation,  or  when  the  tube  is  greatly 
narrowed  by  the  hypertrophy  of  its  lining  membranes,  but  at 
the  same  time  we  have,  as  we  always  do,  in  the  latter  case,  a 
sunken  drum-head,  an  altered  light  spot,  signs  of  proliferous 
inflammation  of  many  of  the  structures  making  up  the  middle 
ear,  I  do  not  see  how  we  can  with  propriety  speak  of  a  tubal 
affection,  even  if  its  symptoms  are  predominant,  and  even  if 
treatment  of,  and  through,  the  lining  membrane  of  the  tube, 
does  place  things  in  such  a  condition  that  Nature  will  com- 
plete the  cure.  No  time  need  be  spent  upon  this  question, 
which  may,  perhaps,  seem  to  some  a  comparatively  unim- 
portant one,  had  not  incorrect  notions  in  the  past  led  to  an 
incorrect  style  of  treatment.  In  former  times,  the  membrana 
tympani,  under  the  assumption  that  such  an  affection  as  an 
independent  chronic  myringitis  existed,  was  vigorously  treated 
by  instillations  of  various  fluids,  and  by  perforation,  and  of 
late,  under  the  idea  that  we  have  a  great  deal  of  tubal  catarrh 


SYMPTOMS  OP  CHRONIC  CATARRH.  263 

without  further  progress  in  the  morbid  action,  undue  stress  is 
sometimes  laid  upon  applications  to  the  mouth  of  the  tube ; 
Politzer's  method  is  substituted  for  the  catheter,  when  its  true 
place,  valuable  and  indispensable  as  it  is,  except  in  the  case  of 
very  young  children,  is  as  an  adjuvant  to  that  instrument. 


SUBJECTIVE  SYMPTOMS    OF   CHRONIC   CATARRHAL    INFLAM- 
MATION. 

I  think  we  may  assume,  from  the  history  of  cases,  that  this 
form  of  disease  is  either  a  consequent  of  frequent  attacks  of 
acute  catarrh  of  the  middle  ear,  or  that  it  occurs  in  people 
who  have  what  we  may  call  a  catarrhal  diathesis.  The  dis- 
ease is,  therefore,  unlike  its  companion,  proliferous  inflamma- 
tion, not  at  all  insidious  in  its  approach.  The  patient  suffer- 
ing from  this  disease,  who  consults  us  about  his  hearing,  is 
usually  aware  that  there  is  an  excess  of  secretion  in  his  pharynx, 
and  that  for  years  he  has  been  annoyed  and  troubled  by  being 
obliged  to  use  a  handkerchief  very  freely,  and  by  feelings  of 
fulness  referred  to  the  frontal  sinus  and  tympanic  cavities. 
There  is  often,  also,  at  times,  a  sound  in  the  ear  like  the  crack- 
ling of  air-bubbles.  The  voices  of  friends  appear  muffled ;  and 
it  is  hard,  for  the  victims  of  chronic  aural  catarrh,  when  the  dis- 
ease is  advancing,  not  to  believe  that  every  one  is  speaking  in 
a  much  lower  tone  than  is  usual  for  them.  Such  patients  often 
complain  bitterly  on  this  subject,  and  will  scarcely  admit  that 
their  hearing  is  at  all  impaired,  or,  if  so,  they  stoutly  assert 
that  it  is  one  ear  only,  when  the  fact  is,  that,  with  one  perfect 
ear,  it  is  only  under  peculiar  circumstances,  certainly  not  in 
ordinary  conversation,  in  front  of  the  patient,  will  a  person  be 
observed  to  be  at  all  hard  of  hearing. 

There  is  a  feeling  about  this  that  is  different  from  that 
expressed  about  diseases  of  the  eye  at  least,  and  I  believe,  in 
most  maladies,  patients  will  express  their  feelings,  and  often 
with  an  exaggeration,  rather  than  with  an  extenuation  of  the 
symptoms  ;  but,  however  much  patients  with  chronic  inflam- 
mation of  the  middle  ear  may  suffer  from  impairment  of  hear- 
ing, they  will  often,  insist  that  they  are  hardly  affected,  or 
that  they  have  a  very  little  trouble  in  that  way,  when  they 


264  VERTIGO   IN   CATARRHAL  INFLAMMATION. 

can  scarcely  hear  loud  conversation  addressed  specially  to 
thein. 

Patients  affected  with  chronic  catarrh  of  the  middle  ear 
also  complain,  as  a  rule,  of  tinnitus  aurium,  and  a  sense  of  ful- 
ness in  the  ears.  The  ears  feel  as  if  the  auditory  canals  were 
stopped  up.  They  often  ask'  very  anxiously  if  there  is  not 
something  in  the  ear,  and  seem  incredulous  when  the  negative 
answer  is  given.  Vertigo  is  another  symptom  of  which  these 
patients  speak,  and  it  is  often  considered  as  undoubted  evi- 
dence that  there  is  disease  of  the  brain.  Vertigo  is  a  symp- 
tom by  no  means  peculiar  to  catarrhal  inflammation.  It  also 
occurs  in  impacted  cerumen,  and  still  more  frequently  in  pro- 
liferous inflammation,  as  well  as  in  cerebral  disease.  When 
vertigo  occurs  in  aural  disease,  it  is  a  consequence  of  increased 
pressure  upon  the  labyrinth  through  the  fenestra  ovalis.  It  is 
by  no  means  a  serious  symptom,  when  the  cause  is  to  be  found 
in  the  middle  ear,  for  it  is  usually  relieved  by  a  mechanical 
treatment  through  the  Eustachian  catheter.  There  are  many 
cases  in  my  note-book  which  illustrate  this,  but  none  more 
striking  than  the  following  : 

A  physician  consulted  me  last  winter  on  account  of  impair- 
ment of  hearing  in  one  ear,  accompanied  by  a  tendency  to 
topple  over  on  that  side,  which  he  said-was  a  consequence  of 
being  thrown  from  his  sleigh  some  months  before,  when  he 
suffered  a  concussion  of  the  brain.  He  was  quite  disposed  to 
regard  the  tendency  to  fall  over  as  a  cerebral  lesion,  but  the 
use  of  the  Eustachian  catheter,  and  Politzer's  method  of  inflat- 
ing the  ear,  not  only  improved  the  hearing,  but  took  away 
the  unpleasant  sensation.  Physician  as  he  was,  he  was 
at  first  disposed  to  smile  at  the  idea  of  using  local  means  to 
ameliorate  this  brain-symptom  ;  but  he  has  continued  to  be 
perfectly  relieved  from  his  cerebral  malady  up  to  this  time, 
nearly  a  year  since  he  consulted  me. 

I  have  often  heard  patients  describe  the  feeling  of  fulness 
in  the  ears  as  a  sensation  as  if  the  ears  were  plugged  with 
some  foreign  substance  ;  it  is  almost  impossible  for  them  to 
avoid  the  impression  that  the  auditory  canals  are  plugged  with 
cerumen.  Very  many  times,  after  I  have*  examined  a  patient 
suffering  from  chronic  disease  of  the  middle  ear,  I  have  been 


INSANITY  FROM  AURAL    DISEASE.  265 

asked  to  look  again  to  see  whether  I  could  not  find  some  hard- 
ened wax ;  and  on  one  occasion  a  poor  fellow,  who  I  suppose 
was,  to  a  certain  extent,  insane,  grew  very  angry  and  called 
me  hard  names,  because  I  would  not  remove  wax  which  he 
knew  was  in  his  ear. 

Yon  Troltsch*  relates  a  case,  from  Meyer,  of  Hamburg, 
where  a  melancholic  person  was  relieved  of  a  sound  in  the  ear, 
seeming  to  him  to  be  the  cry  of  a  child,  by  the  removal  of  a 
plug  of  cerumen,  which  caused  deafness  on  one  side.  The 
patient  made  a  rapid  and  complete  recovery  from  the  mental 
affection,  after  the  cerumen  was  removed.  It  is  the  opinion 
of  Schwartze,t  of  Halle,  a  verj"  careful  and  competent  ob- 
server, that  subjective  aural  sensations,  which  are  caused  by 
demonstrable  affections  of  the  e^ir,  may,  in  predisposed  per- 
sons, especially  when  there  is  any  hereditary  tendency  to  men- 
tal disease,  become  the  direct  cause  of  aural  hallucinations, 
that  may  accelerate  the  outbreak  of  a  disease  of  the  brain. 
He  mentions  a  case  where,  in  his  opinion,  and  in  that  of  one 
of  the  physicians  of  the  Insane  Asylum  at  Halle,  a  threatened 
attack  of  brain  disease  was  prevented  by  treatment  of  the  ear. 
In  some  cases  insane  persons  who  suffer  from  aural  disease 
distinguish  its  tinnitus  from  these  illusions  or  hallucinations. 

Dr.  Koppe  confirms  this  view,  and  shows  that  in  some 
cases  hallucinations  disappear  after  treatment  of  the  ear. 

I  have  elsewhere  reported^:  a  case  of  the  suicide  of  a  pro- 
fessor in  one  of  our  educational  institutions,  who  consulted  me 
on  account  of  impairment  of  hearing,  but  more  especially  on 
account  of  tinnitus  aurium.  He  said,  on  leaving  the  consult- 
ing-room, thai,  if  he  felt  sure  that  I  was  correct  in  my  opinion 
(that  he  would  not  get  great  relief  from  this  very  trying  symp- 
tom, tinnitus),  he  would  put  an  end  to  his  existence  ;  which  he 
did  a  few  months  after,  by  blowing  out  his  brains.  During 
this  last  summer,  a  gentleman,  a  public-school  teacher,  con- 
sulted my  associate,  Dr.  Charles  S.  Bull,  in  regard  to  a  sup- 
puration of  the  ear,  which  caused  considerable  impairment  of 
hearing  and  great  tinnitus.    He  was  exceedingly  depressed 

*  Tejxt-book,  second  American  edition,  p.  531. 

f  Lob.  cit.,  p.  582. 

X  New  York  Medical  Journal,  August,  1869. 


266  INSANITY  FROM  AUKAL  DISEASE. 

and  annoyed  by  the  tinnitus.  It  is  said  that  he  committed 
suicide  on  account  of  the  depression  caused  by  this  state  of 
his  ears.  There  can  be  no  doubt  but  that  this  symptom  is  one 
of  the  most  distressing  that  can  befall  a  patient,  and  that  in 
some  cases  it  is  the  provoking  cause  of  suicide.  Again  and 
again  I  have  satisfied  myself  that  the  great  depression,  which 
is  the  rule  in  persons  whose  hearing  is  impaired,  was  due 
entirely  to  the  aural  disease. 

Dr.  O.  D.  Pomeroy,*  of  this  city,  examined  sixty  lunatics 
at  Blackwell's  Island  Lunatic  Asylum,  and  he  found  disease 
of  the  ear  in  many  of  those  who  suffered  from  what  may  be 
called  aural  hallucinations,  although  this  proportion  was  not  as 
large  as  stated  by  Schwartze  and  Koppe. 

Dr.  C.  E.  Wrightf  publishes  a  case  of  a  patient  in  the  In- 
diana State  Asylum  for  the  Insane,  who  attempted  to  destroy 
herself  by  putting  a  steel  button  in  her  ear.  The  patient  was 
discharged  from  the  hospital,  as  having  recovered  her  reason, 
but  became  nervous  and  despondent,  until  she  was  relieved  by 
the  removal  of  the  button ;  and  a  dread  of  insanity  and  of  sud- 
den death,  from  which  she  suffered,  then  also  disappeared. 

Von  Troltsch  speaks  of  confusion  of  the  intellect,  an  inabil- 
ity to  keep  up  a  connected  line  of  thought,  as  a  subjective 
symptom  of  chronic  aural  disease,  and  I  am  enabled  to  verify 
this  opinion.  Over  and  over  again,  have  patients  with  chronic 
disease  of  the  middle  ear,  not  suffering  from  pain  but  from 
tinnitus,  voluntarily  informed  me  that  these  noises,  together 
with  the  impairment  of  the  hearing,  had  a  great  effect  upon 
their  mental  powers.  On  the  other  hand,  I  have  seen  cases 
where  most  successful  men,  such,  for  instance,  as  distinguished 
general  officers  in  the  army,  and  distinguished  writers,  have 
suffered  from  boyhood  with  chronic  inflammation  of  the  mid- 
dle ear  and  tinnitus  aurium. 

The  sounds  in  the  ears,  of  which  patients  speak,  are 
variously  described  :  some  speak  of  a  ringing  of  bells,  which 
is  perhaps  the  most  aggravating  form  ;  others  have  likened 
them  to  the  murmur  of  trees,  the  hum  of  a  tea-kettle,  etc. 

*  Transactions  of  the  American  Otological  Society,  Fourth  Year,  p.  46. 
f  Indiana  Journal  of  Medicine,  November,  1871. 


TINNITUS  AUEIUM.  2G7 

Wilde  is  undoubtedly  correct  in  stating  that  the  descriptions 
which  patients  give  of  the  noises  depend  to  a  certain  degree 
upon  their  fancy,  their  graphic  power  of  explanations,  and  not 
unfrequently  upon  their  rank  of  life  and  the  sounds  with  which 
they  are  most  familiar;  thus,  he  says:  "Persons  from  the 
country  or  rural  districts  draw  their  similitudes  from  the 
objects  and  noises  by  which  they  have  been  surrounded,  as 
the  falling  and  rushing  of  water,  the  singing  of  birds,  the 
buzzing  of  bees,  and  the  waving  or  rustling  of  trees ;  while,  on 
the  other  hand,  persons  living  in  towns,  or  in  the  vicinity  of 
machinery  or  manufactories,  say  that  they  hear  the  rolling  of 
carriages,  the  hammerings,  and  the  various  noises  caused  by 
steam-engines.  Servants  almost  invariably  add  to  their  other 
complaints  that  they  suffer  from  the  ringing  of  bells  in  their 
ears ;  while,  in  the  country,  old  women  much  given  to  tea- 
drinking  sum  up  the  category  of  their  ailments  by  saying  that 
'  all  the  tea-kettles  in  Ireland  are  boiling  in  their  ears.'  "  No 
description  of  tinnitus  aurium  has  ever  surpassed  this  one 
given  by  the  great  Irish  observer. 

Only  one  thing  more  need  be  added  as  to  the  nature  of 
this  symptom.  The  ordinary  tinnitus  should  be  distinguished 
from  a  venous  murmur  transmitted  from  the  jugular  vein, 
which  runs  just  beneath  the  floor  of  the  cavity  of  the  tym- 
panum, and  from  the  pulsating  sound  of  the  internal  carotid  as 
it  winds  through  the  apex  of  the  petrous  bone.  This  variety 
of  tinnitus  is  not  necessarily  connected  with  impairment  of 
hearing,  but  is  usually  dependent  upon  anaemia  or  aneu- 
rism. 

Patients  suffering  from  chronic  catarrhal  inflammation  of 
the  middle  ear  usually  speak  of  the  throat  as  troubling  them 
quite  as  much  as  their  ears.  In  many  cases,  however,  they 
say  nothing  whatever  about  the  throat,  and  even  if  asked 
about  it,  they  will  insist  that  it  is  quite  well,  although  they 
will  usually  admit  that  they  raise  a  great  deal  of  mucus  in  the 
morning,  and  that  they  have  sore-throat  very  often.  The 
greater  number  of  patients  with  aural  catarrh  complain 
greatly  of  the  condition  of  their  pharynx  and  nostrils,  and, 
under  the  stimulus  of  the  advertisements  and  books  of  char- 
latans, have  usually  very  much  to  say  of  the  catarrh,  although 


268  PEOLIFEROUS    INFLAMMATION. 

they  do  not  always  trace  a  connection  between  the  throat  dis- 
ease and  that  of  the  ear. 

There  are  very  many  other  symptoms  than  these  which 
have  just  been  enumerated — feelings  of  fulness,  confusion  of 
intellect,  vertigo,  tinnitus,  and  sore-throat — of  which  patients 
with  chronic  catarrh  of  the  middle  ear  often  complain ;  but 
they  are  not  usually  dependent  upon  the  aural  disease,  and  the 
examiner  may  often  throw  many  of  them  out  of  consideration, 
and  bring  the  patient  back  from  the  long  story  of  head-aches, 
dyspepsia,  neuralgia,  etc.,  by  asking  whether,  after  all,  if  the 
ear  and  throat  were  well,  they  would  not  consider  themselves 
in  good  health,  when  an  affirmative  answer  is  often  given. 

SUBJECTIVE  SYMPTOMS  OP  PEOLIFEROUS  INFLAMMATION. 

If  we  now  turn  to  the  picture  of  the  subjective  symptoms 
of  what  I  term  proliferous  inflammation,  we  shall  find  them 
much  less  positive  than  those  of  the  catarrhal  form.  Some  of 
the  patients  have  no  subjective  symptoms  at  all,  except  that 
of  loss  of  hearing,  which  is  of  course  an  objective  symptom  as 
well.  They  have  no  sore-throat,  no  increase  of  the  secretion 
of  the  pharynx  or  nostrils.  Others,  again,  complain  of  feel- 
ings of  fulness  in  the  ears,  and  nearly  all  of  tinnitus  aurium. 
Indeed,  I  think  the  tinnitus  is  apt  to  be  more  troublesome  in 
the  proliferous  than  in  the  catarrhal  form.  This  we  should 
suppose  a  priori  to  be  the  case,  because  the  causes  in  the  pro- 
liferous variety  of  middle-ear  disease  are  constantly  acting, 
while  in  the  catarrhal  variety  the  temporary  removal  of  the 
increased  secretion  will  often  greatly  alleviate  this  symptom, 
and  sometimes  completely  remove  it.  The  origin  of  this  form 
of  aural  trouble  cannot  be  traced  back  to  infantile  ear-aches, 
frequent  coryzas,  or  to  naso-pharyngeal  catarrh.  It  is  a  pe- 
culiarly insidious  affection,  one  which  is  usually  under  full 
headway,  and  which  essentially  impairs  the  function  of  hear- 
ing long  before  the  patient  is  aware  that  he  has  any  affection 
of  the  ears.  The  pathology  of  the  disease,  of  which  an  ac- 
count will  be  given  a  little  later  on  in  the  discussion  of  this 
subject,  explains  something  of  this  insidious  character. 

Catarrhal  and  proliferous  inflammation  may  exist  in  one 


CATAEEHAL  INFLAMMATION.  269 

and  the  same  ear,  when  it  will  be  impossible  to  make  a  differ- 
ential diagnosis,  yet  in  the  greater  number  of  cases  the  line 
can  be  drawn  between  the  two  forms. 


OBJECTIVE  SYMPTOMS  OP  CATARRHAL  INFLAMMATION 

The  objective  evidences  of  chronic  catarrhal  inflammation 
of  the  middle  ear  may  be  classified  as  follows  : 

1.  Impairment  of  hearing. 

2.  Changes  in  the  membrana  tympani. 

3.  Imperfect  action  and  clianges  in  the  structure  of  the 
Eustachian  tube. 

4.  Naso-pharyngeal  inflammation. 

If  we  exclude  the  latter,  we  have  also  the  objective  symp- 
toms of  chronic  proliferous  inflammation. 

The  tuning-fork  is  one  of  the  most  useful  means  of  diag- 
nosticating an  affection  of  the  middle  ear  from  one  of     ^     .„ 

,°  m  Fig.  08. 

the  labyrinth.  In  the  catarrhal  form  of  disease  its  use 
is  not  as  essential  as  in  the  proliferous,  for  the  good 
reason  that  the  subjective  and  objective  symptoms 
together  form  such  a  decided  picture  that  it  would  be 
hard  to  fall  into  error  as  to  the  seat  or  nature  of  the 
trouble.  But,  in  the  proliferous  form,  both  sets  of 
symptoms  are  often  of  such  a  negative  character  that 
without  the  tuning-fork  we  should  be  in  some  doubt 
as  to  whether  we  were  dealing  with  a  peripheric  or 
central  disease. 

Starting  from  the  well-established  fact  that,  if  the 
auditory  canal  of  a  person  having  healthy  ears  be 
closed  by  the  finger,  or  in  any  other  way,  the  sound 
made  by  a  vibrating  body  is  heard  more  distinctly  on 
the  side  of  the  head  where  the  ear  is  closed,  it  has 
been  shown  that,  in   most  diseases  of  the  auditory 
canal  and  middle  ear,  such  vibrations  are  more  dis-     Tuning- 
tinctly  felt  on  the  affected  side,  or,  if  one  be  diseased,      fmk' 
on  the  side  of  the  ear  most  affected,  and  on  which  the  ticking 
of  a  watch  or  the  sound  of  conversation  is  not  as  well  heai\d. 
This  subject  has  been  quite  fully  discussed  in  Chapter  II.,  and 


270  BETTER  HEARING  IN   THE   MIDST   OF  NOISE. 

I  beg  to  refer  the  reader  to  that  for  the  different  views  as  to 
the  explanation  of  the  value  of  the  tuning-fork.*  The  use  of 
the  tuning-fork,  as  usually  employed,  must,  however,  be  con- 
sidered to  some  extent  as  a  subjective  test ;  for  when  it  is 
used,  we  must  depend  on  the  patient's  statement  as  to  the 
side  on  which  he  hears  the  vibrations  the  better.  By  means 
of  a  double  diagnostic  tube,  however,  such  as  was  used  by 
Lucae  in  his  experiments,  we  may  make  the  test  more  exact. 

After  having,  in  the  doubtful  cases  of  the  proliferous  vari- 
ety, settled  the  fact  as  to  whether  we  have  an  affection  of  the 
middle  ear  or  of  the  labyrinth,  the  ticking  of  the  watch  and 
ordinary  conversation  become  the  natural  tests  as  to  the  im- 
pairment of  hearing. 

The  watch  is,  however,  an  inadequate  test,  for  the  reason 
that  has  already  been  mentioned  in  the  introductory  chapter, 
that  is,  that  some  persons  can  hear  a  watch  quite  a  number  of 
inches  from  the  ear,  while  they  hear  conversation  very  badly. 
Lucaet  explains  this  fact  by  saying,  that  speech  is  made  up  of 
an  extremely  complicated  system  of  tones,  and  sounds  of  most 
different  tone  heights,  while  the  tick  of  a  watch  is  made  up  of 
a  class  of  very  high  tones.  There  are,  however,  some  cases  in 
which  a  watch  is  not  heard  well,  while  ordinary  conversation 
is  distinctly  appreciated.  Careful  observation  of  the  lips 
of  the  speaker,  by  the  person  whose  hearing  is  defective,  may 
have  something  to  do  with  explaining  this  class  of  cases. 

There  is  a  fact  in  regard  to  the  hearing  power  of  many 
patients  suffering  from  chronic  non-suppurative  inflammation, 
that  does  not  seem  to  have  been  as  yet  satisfactorily  explained. 
It  is  the  fact,  that  these  persons  hear  better  in  noisy  places  than 
their  neighbors  who  have  normal  hearing  power.  For  example, 
such  patients  when  in  a  long  American  railway  carriage,  will 
not  only  hear  with  ease,  the  person  sitting  on  the  same  seat 
with  them,  but  also  the  conversation  of  persons  who  are 
at  such  a  distance  that  a  person  with  normal  ears,  cannot 
distinguish  a  word  they  say.     I  have  often  been  informed  by 

*  The  tuning-forks  usually  employed  are  those  of  the  note  C  such  as  is 
here  represented.  It  is  better  to  strike  them  ou  a  yielding  body,  such  as  the 
knee  of  the  examiner,  than  upon  a  hard  body.     That  of  the  note  B  is  also  used. 

\  Archiv  fur  Ohrenheilkunde,  Bd.  V.,  p.  100. 


CHANGES   IN  THE   MEMBRANA  TYMPANI.  271 

reliable  patients,  that  on  actual  test  they  could  hear  in  such 
places  better  than  persons  with  good  hearing  power.  The  tick 
of  a  watch,  is,  however,  heard  no  further  under  such  circum- 
stances. The  author  once  knew  a  mail  agent,  on  one  of  our 
railways,  who,  although  very  hard  of  hearing,  was  never  sup- 
posed to  be  so,  by  those  who  only  talked  with  him  amid  the 
noise  of  the  train.  I  think  the  explanation  of  this  capability 
of  hearing  better  in  the  midst  of  noises,  will  be  found  to  depend 
upon  an  intensification  or  condensation  of  the  sound  waves,  by 
the  rapid  vibrations  of  the  wheels  of  the  carriages,  and  the  other 
means  by  which  the  sound  is  increased  and  a  place  made  noisy. 
Certain  it  is,  that  some  patients  suffering  from  this  form  of 
disease  of  the  ear  not  only  hear  better  in  noisy  places  than 
in  quiet  ones,  but  also  better  than  persons  with  sound  ears. 
These  phenomena  cannot  be  explained  away  by  any  assertion 
that  they  depend  upon  inexact  observation.  I  have  proved 
them  to  be  facts  by  causing  repeated  experiments  to  be  made. 

CHANGES  IN  THE  MEMBRANA  TYMPANI. 

I  do  not  regard  the  appearance  of  the  drum-head  as  posi- 
tively indicative  of  aural  disease.  In  some  few  cases  we  find 
the  membrane  in  what  may  fairly  be  said  to  be  a  normal  con- 
dition in  appearance,  and  yet  we  may  have  a  very  great  im- 
pairment of  hearing,  which  the  other  objective  symptoms  as 
well  as  the  tuning-fork,  show  to  depend  upon  disease  of  the 
middle  ear.  These  cases  are  not  common,  and  then,  if  the 
loss  of  hearing  is  great,  we  may  conclude  that  the  alterations 
in  structure  are  chiefly  upon  the  inner  or  labyrinth  wall  of  the 
cavity  of  the  tympanum.  I  think,  however,  that  we  very 
rarely  find  an  absolute  sinking  inwards  of  the  membrane, 
unless  attended  by  some  impairment  of  hearing.  A  sunken 
drum-head,  that  is,  one  in  which  the  head  of  the  malleus 
stands  out  like  a  miniature  button,  while  the  whole  membrane 
seems  collapsed  and  sunken,  is  pretty  fair  evidence  of  the 
existence  of  adhesions  in  the  cavity  of  the  tympanum,  and  of 
impairment  of  hearing. 

The  first  question,  in  studying  the  membrana  tympani,  is, 
very  naturally,  "What  is  the  appearance  of  a  normal  one  ? 


272  CHANGES  IN  THE   MEMBEANA   TYHPANI. 

The  introduction  of  Von  Troltsch's  method  of  examining 
the  membrana  tyrupani  has  done  more  than  anything  else  to 
stimulate  the  study  of  its  character.  The  ordinary  anatom- 
ical test-books  give  no  true  idea  of  this  beautiful  and  im- 
portant part.  Such  authorities  on  aural  disease  as  Kramer, 
Wilde,  and  Toynbee,  give  descriptions  of  it  that  are  far  from 
exact.  To  Von  Troltsch  and  Politzer,  are  we  indebted  for  such 
perfect  descriptions  that  we  now  have  a  complete  guide  to  the 
changes  that  may  occur  upon  it. 

In  order  to  determine  what  may  fairly  be  considered  a 
normal  membrana  tympani,  I  have  examined  a  number  of 
what  may  be  considered  healthy  ears.  The  persons  whose 
ears  were  thus  examined  were  not  aware  that  they  had  ever 
had  any  kind  of  aural  inflammation,  even  in  childhood.  They 
did  not  suffer  from  naso-pharyngeal  catarrh,  and  never  had 
suffered  from  it.  The  hearing-distance,  as  tested  by  the 
watch,  was  normal,  and  the  tuning-fork  was  heard  equally 
well  on  both  sides  of  the  head.  Such  persons  are  very  rare  in 
any  community,  and  consequently  I  have  only  as  yet  exam- 
ined seventeen  membranes  belonging  to  this  class.  From 
these  cases,  and  the  observation  of  others,  I  determine  that 
the  color  of  the  membrane  may  vary  from  a  neutral  gray  to  a 
dark  blue  ;  but  it  is  rather  more  inclined  to  a  gray  than  to  a 
blue.  The  lustre  and  transparency  vary  exceedingly ;  the  mem- 
brane may  be  very  brilliant  and  transparent,  so  that  the 
stapes  shows  through,  and  it  may  be  quite  dull  and  hazy  in 
appearance. 

The  light  spot  at  the  end  of  the  malleus  is  usually  trian- 
gular in  shape,  although  not  always.  It  is,  perhaps,  always 
present  in  some  form  if  the  hearing  be  normal.  The  head, 
handle,  and  short  process  of  the  malleus  are  plainly  visible. 
There  may  be  opacities  at  the  margin  of  the  membrane,  where, 
as  Troltsch  showed,  the  mucous  membrane  is  thickest.  The 
gray  color  may  be  modified  by  a  delicate  pinkish  injection  along 
the  periphery  of  the  membrane  and  handle  of  the  malleus. 

It  is  not  uncommon  to  find  chalky  spots  or  points  of  cal- 
careous degeneration  in  the  membrana  tympani.  They  are 
found  not  only  in  the  ears  of  persons  with  impaired  hearing, 
but  also  in  those  whose  hearing  power  is   acute.     Undue 


CALCAEEOUS  FORMATIONS.  273 

weight,  should,  therefore,  not  be  attached  to  these  appear- 
ances. 

Von  Troltsch*  seems  to  have  been  disposed  to  regard  these 
calcareous  formations  as  connected  with  high  degrees  of  im- 
pairment of  hearing,  but  I  have  not  found  this  to  be  necessa- 
rily the  case.  Politzer  f  regards  them  as  the  products  of  sup- 
purative processes  that  have  run  their  course.  In  some  cases, 
as  we  know,  such  inflammatory  affections  are  perfectly  recov- 
ered from,  and  if  the  calcareous  degeneration  do  not  occur  on 
an  important  part  of  the  membrane,  it  probably  will  produce 
no  impairment  of  hearing  of  itself. 

Moos  has  proved  by  one  case  which  he  observed,  that  a 
calcareous  degeneration  may  occur  in  the  course  of  a  non- 
suppurative process.  This  case  was  that  of  a  woman  more 
than  seventy  years  of  age,  who  had  chronic  catarrh  of  the 
middle  ear. 

Calcareous  degenerations,  as  shown  by  the  microscopic 
examinations  of  Politzer,  usually  occur  in  the  fibrous  layer. 
Where  the  deposit  is  not  very  thick,  the  integument  was  quite 
easily  separated  from  the  calcified  parts.  The  mucous  layer 
was  a  little  more  adherent.  In  some  cases  both  the  external 
and  middle  layers  were  involved  in  the  calcific  process.  Po- 
litzer once  found  a  true  osseous  deposit,  together  with  the  cal- 
careous degeneration,  in  one  of  his  cases.  Black  or  dark  brown 
pigment  was  also  found  by  him  and  fat  globules  everywhere. 

An  acute  catarrh  of  the  middle  ear  in  childhood  is  suffi- 
cient to  change  the  color  or  curvature  of  the  membrana  tym- 
pani,  and  thus  render  it  impossible  to  say  that  we  are  dealing 
with  a  normal  membrane.  The  membrana  tympani  of  the 
child  differs  from  that  of  the  adult  in  being  more  transparent, 
while  it  is  rather  of  a  yellowish  tinge  than  gray,  and  the  han- 
dle of  the  malleus  is  not  as  distinctly  seen. 

Politzer  has  shown,  in  his  work  on  this  membrane,  that  the 
triangular  spot  of  light,  which  is  one  of  the  chief  points  for 
study  in  this  part,  is  due  to  the  manner  of  the  reflection  of 
light  from  its  surface,  and  the  factors  which  cause  this  reflec- 
tion have  been  fully  detailed  on  page  189. 

*  Politzer,  The  Membrana  Tympani,  p.  58. 
|L.c. 

18 


274  TRIANGULAR  LIGHT  SPOT. 

Politzer*  believes  that  we  can  form  no  conclusions  as  to 
changes  in  the  cavity  of  the  tympanum  andmembrana  tympani, 
from  alterations  in  the  size  and  shape  of  the  light  spot ;  but  I 
cannot  endorse  this  view.  In  the  first  place,  if  changes  have 
taken  place  in  the  outer  layer,  or  layer  of  epidermis,  the 
reflecting  power  of  the  membrane  is  nearly  removed,  and  there 
is  no  light  spot.  Its  absence  certainly  indicates  changes  in 
the  drum-head.  Again,  if  it  be  smaller  than  usual,  or  if  it  can 
be  changed  in  form  by  the  Valsalvian  experiment,  or  by  other 
methods  of  inflating  the  middle  ear,  I  think  we  may  draw 
quite  positive  and  valuable  conclusions  as  to  the  traction  ex- 
erted by  the  malleus,  and  as  to  the  inclination  of  the  mem- 
brane. I  do  not  deny  that  we  may  find  an  irregular  or  small 
light  spot  on  a  person  with  normal  hearing  power;  but  I 
believe  that  such  a  state  of  things  is  rare,  and  that  its  shape 
and  size  will  be  found  to  be,  in  the  majority  of  cases,  a  pretty 
fair  guide  in  a  general  way,  as  to  the  loste  of  function.  From 
the  notes  of  94  ears  affected  with  chronic  non-purulent  inflam- 
mation of  the  middle  ear,  seen  at  the  Manhattan  Eye  and 
Ear  Hospital,  and  recorded  by  Dr.  D.  Webster,  it  is  recorded 
that — 

In  59  the  light  spot  was  present. 
35       "  "         absent. 

9       "  "         normal. 

44       "  "         smaller. 

2       "  "         larger. 

4       "  "         divided  (i.  e.,  2  or  more  light  spots  existed). 

The  experiments  of  Magnus  in  compressed  air,  which  have 
been  alluded  to  in  the  chapter  on  Injuries  of  the  Membrana 
Tympani,  also  prove  that  the  non-existence  of  the  light  spot 
does  show,  that  the  membrana  tympani  is  forced  or  drawn 
inwards. 

CHANGES  IN  MOBILITY  OF  MEMBRANA   TYMPANI. 

If  a  person,  having  normal  hearing  power,  forces  the  air 
into  the  cavities  of  the  tympanum  by  a  prolonged  inspiration 
and  expiration,  with  the  nostrils  closed,  he  has  performed  the 

*  The  Membrana  Tympani,  translated  by  Mathewson  and  Newton,  p.  8. 


VALSALVIAN  METHOD.  275 

Valsalvian  experiment  for  testing  the  permeability  of  the 
Eustachian  tubes,  and,  on  examination  during  this  act,  we  find 
that  the  membranes  moved  outward  and  then  inward.  This 
change  takes  place,  in  a  healthy  membrane,  chiefly  at  the 
apex  of  the  light  spot,  or  extremity  of  the  malleus  ;  but  it  may 
occur  in  other  parts,  especially  in  Shrapnell's  membrane.  In 
the  catarrhal  form  of  affections  of  the  middle  ear,  the  mobility 
of  the  drum-head  is  not  affected  to  any  extent.  It  may  be 
even  preternaturally  movable.  In  the  proliferous  variety,  how- 
ever, adhesions  are  apt  to  occur  between  the  malleus  and  the 
membrane,  and  between  the  other  ossicula,  and  these  will  seri- 
ously affect  the  normal  movements  of  the  drum-head  and  the 
chain  of  bones.  It  is  true,  however,  that  mere  swelling  of  the 
membrane,  such  as  obtains  in  the  second  stage  of  the  catarrhal 
form,  will,  to  some  extent,  affect  the  motions  of  these  parts. 

It  should  not  be  thought,  however,  that  the  middle  ear  is 
in  a  normal  condition,  because  a  drum-membrane  moves. 
The  membrane  may  move  well,  and  yet  the  most  serious 
changes  may  have  taken  place  in  the  cavity  behind  it.  Pa- 
tients who  suffer  from  impairment  of  hearing  have  pretty 
generally  learned  the  Yalsalvian  test  or  experiment,  and,  when 
they  are  so  deaf  as  not  to  hear  ordinary  conversation  at  all, 
and  have  been  so  for  years,  they  will  often  triumphantly,  and 
with  great  skill,  show  the  examiner  how  well  they  can  blow 
air  into  their  ears,  as  evidence  that  there  can't  be  very  much 
the  matter  with  them  after  all.  The  promulgation  among  the 
laity  and  profession  of  the  valuable  character  of  this  experi- 
ment has  harmed  many  ears.  It  is  an  experiment  simply. 
Its  chief  value  belongs  to  the  observer.  It  is  an  abuse  of  it 
to  make  it  a  method  of  treatment.  It  can  be  theoretically 
demonstrated  that  it  is  even  a  somewhat,  although  slightly, 
dangerous  experiment  to  persons  at  all  disposed  to  congestion 
of  the  head  and  neck ;  but  this  danger  is  not  great  enough  to 
lead  the  practitioner  to  wholly  abandon  it  as  a  means  of  treat- 
ment, were  it  not,  as  I  believe,  almost  useless  therapeutically, 
and  dangerous  to  the  integrity  of  the  tension  of  the  membrana 
tympani.  I  very  often  see  patients  who  have  learned  this 
method  of  treatment,  and,  having  believed  that  no  harm  could 
ensue  from  a  very  frequent  performance  of  the  experiment, 


276 


siegle's  otoscope. 


have  been  in  the  habit  of  inflating  the  membrana  tympani 
several  times  a  day.  A  membrane  that  has  been  thus  treated 
becomes  very  flaccid,  and  flaps  to  and  fro,  at  every  swallowing 
motion,  like  the  sign-board  of  a  country-inn  on  a  windy  day. 

Siegle's  otoscope,  a  representation  of  which  is  here  given, 
enables  us  to  form  pretty  accurate  notions  of  the  mobility  of 
the  membrane.     The  air  may  be  exhausted  by  means  of  the 


Fig.  59. 


iSiegle's  Speculum. 

lips,  while  the  membrane  is  carefully  watched  for  its  move- 
ment, or  a  syringe  may  be  used  by  an  assistant  for  the  same 
purpose,  while  the  surgeon  examines  the  movements  of  the 
drum-head.  Care  should  be  taken  that  the  speculum,  as  it 
should  be  called,  fit  accurately  in  the  auditory  canal,  so  that 
a  real  exhaustion  of  the  air  may  occur.  Of  course,  the  oto- 
scope must  be  used  to  examine  the  drum-head  through  the 
glass  of  the  speculum. 


CHANGES  IN  THE  EUSTACHIAN  TUBE. 

Having  considered  the  appearance  of  the  drum-head  in 
cases  of  chronic  non-suppurative  inflammation  of  the  middle 
ear,  we  have  next  to  examine  the  Eustachian  tube  and  pha- 
rynx, and  note  the  changes  which  appear  there.  At  this  point 
the  boundary  line  may  be  distinctly  drawn  between  the  ca- 
tarrhal form  and  the  proliferous  form  of  inflammation.  In  the 
former  class  of  cases,  the  pharynx  and  Eustachian  tube  show 
marked  evidences  of  morbid  action ;  while  in  the  latter  there 


PHAEYNGITIS   GEANULOSA.  277 

are  scarcely  any  changes  in  the  pharynx,  and  often  no  very 
striking  ones  in  the  Eustachian  tube.  The  pharynx,  in  a  true 
case  of  catarrhal  inflammation  of  the  middle  ear,  is  found  in 
one  of  the  following  conditions  : 

There  may  be  great  swelling  of  the  pharynx  and  of  the 
tonsils,  with  or  without  increase  in  the  amount  of  secretion. 
There  may  be,  however,  excess  of  secretion,  without  any  con- 
siderable swelling.  In  such  cases  the  patient  is  usually  very 
conscious  of  the  trouble  in  his  throat.  He  may  not  be 
aware  of  any  pharyngeal  affection,  and  yet  have  a  pharynx 
that  is  considerably  relaxed  and  swollen.  If  these  two  symp- 
toms be  not  present  to  any  marked  extent,  we  usually  find 
minute  round  elevations  scattered  over  the  surface,  or  grouped 
in  an  arch  under  the  uvula.  These  constitute  the  disease 
known  as  pharyngitis  granulosa.     The  pathological  condition 

Fig.  60. 


Pharyngitis  granulosa. 

This  engraving  was  made  from  a  drawing,  by  Mr.  Q,  C.  Wright,  of  the  pharynx  of  a  young 
lady,  who  had  suffered  for  many  years  from  a  chronic  suppurative  inflammation  of  the 
middle  ear  ;  but  it  is  a  fair  type  of  some  of  the  worst  cases  of  granular  pharyngitis,  as 
seen  in  chronic  catarrhal  inflammation. 

is  a  stoppage  of  the  secretions,  and  subsequently  hypertrophy 
of  the  structure.  This  affection  is  called  by  some  authors 
chronic  follicular  pharyngitis,  and  its  more  advanced  stages 
glandular  hypertrophy  ;  but  I  prefer  the  simple  nomenclature 
of  pharyngitis,  in  the  stage  of  increased  secretion  and  swelling, 


278  APPEAEANCES  OF  EUSTACHIAN  TUBE. 

and  granular  pharyngitis,  when  these  characteristics  of  the 
inflammation  are  less  prominent,  but  where  the  granulations 
or  hypertrophic  glands  are  very  marked  in  appearance.  If 
the  tonsils  are  not  enlarged,  they  often  exhibit,  by  a  jagged 
appearance,  the  evidence  of  former  disease. 

The  rhinoscope  often  exhibits  the  same  condition  of  the  mu- 
cous membrane  about  the  mouths  of  the  Eustachian  tube.  Dr. 
O.  D.  Ponieroy*  characterizes  these  appearances  as  follows,viz. : 

"I. — Mucus  in  the  mouth  of  the  tube,  with  or  without 
greenish  or  grayish  mucus  clinging  or  adherent  to  the  post- 
nasal septum,  and  occasionally  filling  the  nares. 

"  II. — Increased  redness  in  and  about  the  mouth  of  the 
tube,  or  paleness  of  the  mucous  lining  of  the  part. 

"  III. — An  cedematous  condition  of  the  parts  near  and  in 
the  mouth  of  the  tube,  resulting  in  more  or  less  of  swelling. 

"  The  swelling  in  the  region  of  the  tube,  the  result  of 
hyperemia  or  oedema,  may — 1.  So  far  obliterate  the  mouth 
of  the  tube  as  to  cause  it  to  appear  as  a  minute  dimple,  or 
obliterate  it  entirely  ;  or — 2  Produce  so  much  swelling  of  the 
collar-like  surrounding  of  the  tube  as  to  greatly  exaggerate  it. 
3.  Increase  the  elevation  which  separates  the  mouth  of  the 
tube  from  the  fossa  of  Rosenmuller.  4.  Enlarge  the  posterior 
extremities  of  the  middle  and  inferior  turbinated  bones,  and 
produce  a  malposition  in  posterior  nares,  and  give  it  a  rough 
and  uneven  outline.  5.  Cause  a  ring-like  swelling  around  the 
tube,  rough,  red,  and  of  a  macerated  appearance. 

"  TV. — Granulations  similar  to  those  found  in  the  pharynx 
in  granular  pharyngitis  near  the  mouth  of  the  tube. 

"V. — Polypi  in  the  posterior  nares,  and  more  frequently 
on  the  turbinated  bones. 

"  VI. — An  apparent  diminution  in  the  mobility  of  the  lips 
of  the  tube  during  contraction  of  its  muscles. 

"  VII. — Whitish  striae,  indicating  cicatricial  degeneration  of 
the  proper  substance  of  the  mucous  membrane  in  the  region 
of  the  Eustachian  tube." 

Very  many  of  the   patients  who  suffer  from  pharyngeal 

*  Letter  to  writer. 


EUSTACHIAN  CATHETEB.  279 

and  nasopharyngeal  inflammation,  scarcely  speak  of  it  when 
asking  advice  in  regard  to  the  disease  of  the  ears,  and  it  is 
only  on  close  questioning  that  they  will  admit  that  they 
are  annoyed  by  the  accumulation  of  mucus  in  the  throat,  caus- 
ing frequent  expectoration,  hawking,  and  the  other  symptoms 
of  chronic  pharyngeal  catarrh.  At  other  times  the  catarrh,  as 
they  term  it,  is  the  great  burden  on  their  minds,  and  they  talk 
freely  of  the  stuffed  feeling  in  the  head,  and  describe  their 
symptoms  in  a  graphic  style,  that  has  been  obtained  by  a  dili- 
gent perusal  of  the  advertising  columns  of  the  daily  news- 
papers. 

The  Eustachian  catheter  is  a  very  valuable  means  of  diag- 
nosticating not  only  the  changes  in  the  cavity  of  the  tympanum, 
but  also  those  in  the  naso-pharyngeal  space.  In  passing  this 
instrument  through  the  nostrils  it  should  always  be  used  as  a 
sound,  and  the  condition  of  this  portion  of  the  mucous  tract 
carefully  noted.  The  inferior  meatus  is  often  found  swollen 
and  even  granular.  In  some  cases  nasal  polypi  may  exist. 
The  catheters  usually  employed  are  of  three  sizes,*  but  it  will 
be  found  that  one  still  smaller  than  that  usually  employed  is 
needed,  not  on  account  always  of  the  swelling  or  hypertrophy 
of  the  membrane,  but  of  some  abnormal  position  of  the  sep- 
tum which  renders  the  canal  very  narrow  and  irregular.  The 
way  in  which  the  air  passes  through  the  catheter  into  the  tube 
is  deemed  by  many  as  of  much  importance  in  the  diagnosis 
of  chronic  catarrhal  or  plastic  inflammation.  The  passage 
of  a  full  and  strong  current  almost  necessarily  precludes 
the  idea  of  any  considerable  change  in  the  calibre  of  the 
Eustachian  tube,  unless  it  be  atrophy  of  its  tissue.  The 
mere  fact  that  air  can  be  made  to  enter  the  tube,  either  by 
the  Valsalvian  experiment,  the  Eustachian  catheter,  Toyn- 
bee's  or  Politzer's  method ;  in  other  words,  the  fact  that  the 
Eustachian  tube  is  open,  so  that  the  patient  perceives  the  ful- 
ness in  the  ears  which  shows  that  a  column  of  air  has  been 
forced  against  that  already  in  the  middle  ear,  is  no  evidence 
whatever,  that  the  ear  is  in  a  healthy  condition.  In  my  own 
experience,  closure  of  the  Eustachian  tube  is  one  of  the  rarest 

*  Two  of  the  catheters  are  figured  in  actual  size  on  page  94. 


280 


NOTES    EUSTACHIAN  CATHETER. 


FlG-  61-  of  conditions.  I  mean,  by  clos- 

ure, such,  a  state  of  things,  that, 
by  trial  of  the  catheter  and 
Politzer's  method,  the  air  can- 
not be  made  to  enter  the  ear. 

The  two  nostrils  often  differ 
in  size  very  much.  This  differ- 
ence is  usually  due  to  a  devia- 
tion of  the  septum  to  one  side 
or  the  other,  in  consequence 
perhaps,  of  an  injury  received 
when  the  patient  was  young, 
and  the  bone  was  soft.  In 
some  very  rare  cases  not 
even  the  smallest  catheter 
that  can  be  made,  can  be 
passed  through  the  nostril  of 
one  side.  For  such  cases  the 
catheter  has  usually  been 
made  longer,  and  introduced 
through  the  opposite  nostril ; 
but  Dr.  Noyes,*  of  this  city, 
thinks  that  this  method  is 
not  reliable,  because  by  it 
the  air  simply  passes  "  across 
the  axis  of  the  Eustachian 
tube,  and  if  it  pass  up  the 
tube  at  all,  it;  can  only  do  so 
after  being  reflected  from  the 
outer  wall  of  the  trumpet  ori- 
fice." 

Dr.  Noyes  has  therefore 
modified  the  catheter  usually 
employed,  by  giving  the  beak 
a  double  curve. 

The  engraving  shows  the 
exact  size  and  shape  of  the 
instrument  invented  by  Dr. 

Noyes1  Eustachian  Catheter. 

*  Transactions  of  the  American  Otological  Society,  1870. 


NOYES'   EUSTACHIAN   CATHETEE.  281 

Noyes.  The  following  are  his  directions  for  using  it.  "  When 
introducing  the  catheter,  it  is  needful  to  keep  the  front  close 
to  the  septum,  as  well  as  to  the  floor  of  the  nostril.  Arrived 
at  the  posterior  edge  of  the  septum,  the  beak  should  wind 
closely  around  it,  curving  obliquely  across,  and  turning  up- 
ward, so  as  to  point  toward  the  Eustachian  orifice." 

In  order  to  test  the  permeability  of  the  tubes,  the  subse- 
quent examination  of  the  membrana  tympani  and  the  patient's 
own  sensations  become  important  evidences.  The  membrana 
tympani  may,  however,  become  reddened  by  the  mere  appli- 
cation of  instruments  to  the  external  meatus,  and  to  the  mouth 
of  the  tube,  so  that  we  must  be  careful  to  exclude  such  sources 
of  error. 

The  diagnostic  tube  of  Toynbee,  by  means  of  which  we 
listen  to  the  sounds  of  the  air  passing  through  the  tube  up  to 
the  drum-head,  is  also  a  valuable  assistance  in  determining 
the  patency  of  the  tube  and  the  size  of  the  cavity  of  the  tym- 
panum.* Kramer  claims  to  determine,  by  the  use  of  the  diag- 
nostic tube,  the  character  of  "  exudation  "  and  the  width  of  the 
tube.  If  there  is  a  piercing  {durcligeiiendes) ,  near,  rattling,  vesi- 
cular sound,  he  then  diagnosticates  the  existence  of  a  free  exu- 
dation. If,  however,  a  sonorous,  near,  vesicular  sound,  it  is 
proof  that  there  is  no  free  exudation  ;  if  there  is  a  distant,  muf- 
fled, vesicular  sound,  then  we  are  dealing  with  sub-mucous 
exudation,  which  is  united  to  free  exudation,  and  so  on.  I 
only  quote  these  from  the  last  edition  of  Kramer's  book,  to 
show  to  what  lengths  a  man  may  go  in  riding  a  hobb}7 ;  for 
Kramer's  hobby  is  the  diagnosis  of  the  affections  of  the  middle 
ear,  by  the  sounds  heard  through  the  diagnostic  tube,  caused 
by  blowing  through  his  catheters. 

The  true  value,  however,  of  the  diagnostic  tube  is  only  in 
connection  with  the  other  means  that  have  been  mentioned, 
the  appearance  of  the  membrana  tympani,  and  the  patient's 
own  sensations. 

PATHOLOGY. 

After  the  clinical  investigations  of  Kramer  and  Wilde,  the 
first  great  advance  that  was  made  in  otology  were  the  dissec- 

*  See  engraving  on  page  97. 


282  PATHOLOGY. 

tions  of  Toynbee.  The  museum  of  preparations  illustrative 
of  diseases  of  the  ear,  in  London,  is  a  memorial  to  Joseph 
Toynbee,  that  will  be  as  enduring  as  scientific  truth.  From 
the  time  of  Toynbee  until  now,  the  dissection  of  ears  of  those 
who  were  known  to  be  deaf  continues  ;  and  from  the  labors 
of  Yon  Troltsch,  Schwartze,  Yoltolini,  Hinton,  Gruber,  Orne 
Green,  Moos,*  and  others,  we  have  verified  on  the  dead  bodies 
diseases  that  have  been  diagnosticated  in  the  living  one,  or,  I 
should  rather  say,  we  have  learned,  from  the  inspection  of  the 
ears  of  the  cadaver,  what  is  probably  the  condition  of  ears 
in  life. 

The  pathological  appearances  in  chronic  catarrhal  inflam- 
mation are — 

1.  Collections  of  mucus  distending  the  cavity  of  the  tym- 
panum. 

2.  Thickened  mucous  membrane. 

3.  Filling  up  of  the  cavity  by  lymph. 


PATHOLOGY  OF  PROLIFEROUS  INFLAMMATION. 

In  the  form  of  inflammation  that  shows  a  higher  formation 
than  the  catarrhal,  there  are  changes  which  may  have  resulted 
directly  from  the  increase  of  secretion  ;  but  the  stage  of 
catarrh  having  completely  passed  over,  or,  in  some  cases, 
never  having  existed,  these  pathological  appearances  may 
be  properly  classed  together  as  evidences  of  what  I  have  ven- 
tured to  designate  the  proliferous  form.     They  are  : 

1.  Connective-tissue  formations  in  the  cavity  of  the  tym- 
panum. 

2.  The  mucous  membrane  of  the  tube  covered  by  dense 
fibrous  tissue. 

3.  Hypertrophy  of  the  bony  walls  of  the  tube. 

4.  Obstruction  of  the  tube  and  cavity  of  the  tympanum  by 
dense  fibrous  tissue. 

*  A  Descriptive  Catalogue  of  Preparations  Illustrative  of  the  Diseases  of 
the  Ear.  London,  1857.  Archiv  fur  Ohrenheilkunde,  Bd.  I.-V.  Monatsschrift 
far  Ohrenheilkunde.  Guy's  Hospital  Reports.  Gruber's  Lehrbuch.  Transac- 
tions American  Otological  Society.    Moos'  Klinik  der  Ohrenkrankheiten. 


PATHOLOGY.  283 

5.  The  stapes  bone  completely  and  firmly  anchylosed  to 
the  margin  of  the  fenestra  ovalis. 

6.  An  exostosis  on  the  inner  surface  of  the  neck  of  the 
malleus. 

7.  Malleus  and  incus  anchylosed  together. 

8.  Firm  bands  of  adhesions  in  the  mastoid  cells. 

9.  False  membrane  on  the  tendon  of  the  tensor  tympani 
muscle. 

10.  Partial  obliteration  of  the  cavity  of  the  tympanum 
from  adhesions  of  the  membrana  tympani  to  the  labyrinth 
wall. 

11.  Hyperostosis  of  the  petrous  bone,  and  anchylosis  of 
both  stapes. 

12.  Atrophy  and  fatty  degeneration  of  the  tensor  tympani. 

These  are  actual  appearances,  of  individual  cases  taken 
from  Toynbee's  catalogue  and  from  the  writings  of  the  other 
authorities  whom  I  have  mentioned ;  some  of  them  are  per- 
haps consequences  of  suppurative  inflammation,  although  I 
have  been  careful  to  exclude  all  cases  in  which  there  was  loss 
of  the  membrana  tympani,  or  other  positive  evidence  of  a  sup- 
purative process. 

Gruber's*  account  of  the  pathology  of  otitis  media  hyper- 
trophica  is,  that,  "  from  some  cause  or  other,  there  is  first  a 
great  hyperemia  with  distention  of  the  membrane,  and  in  part 
the  new  formation  of  blood-vessels,  and  increase  of  the  inter- 
cellular fluid.  The  connective-tissue  corpuscles  are  increased. 
The  tissue  of  the  inflamed  mucous  membrane  is  less  moist 
than  in  the  catarrhal  form.  The  new  formations  or  new  ele- 
mentary formations  go  on  to  a  higher  development.  The 
most  various  adhesions  may  occur,  or  a  soft  connective  sub- 
stance appears  which  is  either  evenly  spread  over  the  whole 
portion  that  was  originally  inflamed,  and  thus  leads  to  hyper- 
trophy of  the  mucous  membrane,  or  it  may  go  on  to  granular 
formation.  Many  of  these  new  formations  may  also  undergo 
regressive  metamorphosis — they  may  undergo  molecular  dis- 
integration, become  fatty,  and  be  absorbed." 

*  Lehrbucb.  der  Obrenbeilkunde,  S.  516.    Wien,  1870. 


284  CAUSES   OF  INFLAMMATION  OF  THE  MIDDLE  EAK. 


CAUSES. 

I  have  endeavored,  in  recording  the  histories  of  about 
fifteen  hundred  cases  of  aural  disease  observed  in  private 
practice,  to  give  the  probable  remote  and  proximate  causes. 
These  are  only  to  be  obtained  by  a  strictly-observed  system 
of  cross-questioning,  since,  by  far  the  greater  number  of 
patients  ascribe  their  disease  to  causes  which  are  certainly 
very  remote  if  not  doubtful,  and  to  others  which  have  cer- 
tainly had  no  influence.  Thus  patients  will  assert  that  their 
loss  of  hearing  results  from  cold,  when  they  cannot  remember 
that  they  ever  had  a  severe  cold  affecting  the  ears,  but  they 
conclude  that  it  must  have  been  a  cold  ;  others,  again,  declare 
that  their  throats  have  always  been  well,  that  they  seldom 
require  to  use  a  handkerchief,  and  yet  an  examination  will 
reveal  a  bad  condition  of  the  naso-pharyngeal  mucous  mem- 
brane. 

Judging  as  well  as  I  am  able,  from  my  experience  in  public 
as  well  as  private  practice,  I  am  disposed  to  consider  the 
following  as  among  the  most  probable  causes  of  chronic  non- 
suppurating  inflammation  of  the  middle  ear  : 

Remote. — 1.  A  feeble  state  of  the  system,  due,  for  exam- 
ple, to  inherited  or  acquired  syphilis,  phthisis  pulmonalis,  etc. 

2.  Defective  hygienic  management,  e.  g.,  neglect  of  bathing, 
want  of  exercise  in  the  open  air,  lack  of  proper  food,  etc. 

Proximate. — 1,  Repeated  attacks  of  acute  catarrh  of  the 
pharynx  and  middle  ear,  a  disease  popularly  known  as  ear- 
ache. 

2.  Naso-pharyngeal  inflammation. 

3.  Diseases  of  the  lungs  and  bronchial  tubes. 

These  proximate  causes  are  chiefly  to  be  made  out  in  the 
catarrhal  form  of  chronic  inflammation,  while  in  the  prolifer- 
ous form,  the  practitioner  is  often  greatly  in  doubt,  as  to  what 
may  have  been  the  origin  or  exciting  cause  of  the  insidious 
affection  which  goes  on  so  steadily  to  change  of  structure  and 
loss  of  function.  Indeed,  we  are  often  obliged  to  be  content 
to  acknowledge  the  fact  of  change  of  structure  without  being 
able  to  definitely  assign  a  cause  for  it.  Why  the  changes  that 
make  up  a  true  case  of  proliferous  inflammation,  or  one  of  a 


CAUSES   OF  INFLAMMATION   OF  THE   MIDDLE  EAR.  285 

bastard  form  in  which  the  proliferous  element  predominates, 
continue  to  advance  in  spite  of  treatment  and  of  proper 
hygienic  management,  is  one  of  the  most  disheartening  pro- 
blems that  a  practitioner  who  treats  aural  disease  attempts  to 
solve.  It  is  not  strange,  that  cases  of  insidiously  advancing 
impairment  of  hearing,  dependent  upon  illy  defined,  but  posi- 
tive causes,  have  excited  the  minds  of  physicians  to  adopt 
even  what  may  appear  to  be  fanciful  means  for  their  cure. 
The  history  of  coryzas  and  ear-aches,  and  of  chronic  sore- 
throats,  is  usually  distinct  enough  in  chronic  catarrhal  inflam- 
mation, and  even  if  there  be  no  such  history,  then  the  appear- 
ances of  the  pharynx,  and  the  results  of  tactile  investigation 
of  the  tubes,  are  sufficient  to  allow  us  to  determine  just  what 
kind  of  a  process  has  been  going  on. 

It  would  be  interesting  to  accurately  trace  the  origin  of  these 
proximate  causes.  "We  should  find,  I  think,  that  the  most  of 
them  were  due  to  neglect,  or  improper  management ;  for  exam- 
ple, the  heads  of  some  children  are  oftentimes  vigorously  washed 
without  being  thoroughly  dried;  they  are  allowed  to  remain 
in  water  unduly  long  ;  their  legs  and  chests  are  left  uncovered 
in  weather  in  which  strong  men  are  clad  in  beaver-cloth,  and 
women  in  furs  ;  they  play  about  the  streets,  and  sit  down, 
when  tired  and  warm,  on  the  damp  and  cold  stone  steps  of 
city-houses  ;  they  are  held  thoughtlessly  by  an  open  window 
on  a  cold  day  ;  they  are  warmly  clad  by  day  but  insufficiently 
covered  at  night ;  in  short,  the  temperature  of  the  body  is  not 
properly  regulated,  and  a  pharyngeal  catarrh  passes  in  an 
instant  to  the  tympanic  cavity,  where  it  is  an  acute  catarrh. 
If  the  acute  catarrh  does  not  go  on  to  suppuration,  it  is  half 
recovered  from  under  the  use  of  anodynes  applied  to  the  outer 
surface  of  the  drum-membrane  ;  in  which  a  thickening  is  left 
which  forms  a  good  basis  for  a  case  of  gradual  and  mysterious 
middle-ear  trouble,  and  with  no  known  cause.  In  large  towns 
where  the  system  of  drainage  or  sewerage  is  sometimes  im- 
perfect, foul  air  may  be  forced  back  through  the  water-pipes, 
and  becomes  a  cause,  often  unsuspected,  of  catarrhs  of  the 
worst  type. 

With  older  people  a  slight  and  neglected  coryza  or  pharyn- 
gitis is  followed  by  a  fulness  in  the  ears,  that  "will  wear 


286  CAUSES   OF  INFLAMMATION   OF  THE   MIDDLE  EAE. 

away,"  and  which  does  wear  away  in  part ;  but  if  it  occurs  in 
persons  who  have  no  good  hygienic  habits  in  such  matters  as 
bathing,  temperance,  and  so  forth,  it  leaves  behind  a  residuum 
of  hypersecretion  or  proliferation,  which,  as  has  been  said,  is 
the  foundation  for  repeated  attacks,  and,  finally,  of  permanent 
thickening. 

The  syphilitic  catarrh  of  infants  and  young  persons,  is  the 
frequent  cause  of  an  affection  of  the  middle  ear,  which,  unlike 
its  frequent  companion,  interstitial  keratitis,  is  one  of  the 
worst  forms  of  disease  in  the  obstinacy  with  which  it  resists 
all  treatment.  The  eyes  may,  and  generally  do,  get  well ;  but, 
if  once  the  tympanic  cavities  be  attacked,  intra-auricular  adhe- 
sions occur,  the  membrana  tympani  is  drawn  inward,  the  nerve 
is  secondarily  involved,  and  the  loss  of  hearing  often  becomes 
almost  complete. 

There  are  no  peculiar  aural  symptoms  by  which  we  may 
positively  distinguish  a  case  of  chronic  disease  of  the  middle 
ear  that  was  caused  by  syphilis,  from  one  occurring  in  a  non- 
syphilitic  patient.  Yet  we  may  say  in  general,  that  a  syphi- 
litic diathesis  seems  to  cause  the  proliferation  of  tissue  to  be 
more  rapid  and  less  amenable  to  treatment.  Schwartze  be- 
lieves that  the  pathological  change  in  these  syphilitic  cases  is 
a  periostitis,  and  this  view  seems  to  be  correct. 

Just  how  it  is,  that  pregnant  women  are  so  often  affected 
by  a  proliferous  inflammation  of  the  middle  ear,  I  am  unable 
to  say ;  but  it  is  a  fact,  that  many  women  have  told  me,  that 
they  traced  their  impairment  of  hearing  to  their  first  preg- 
nancy, and  that  they  became  worse  at  the  birth  of  each  child. 
I  am  now  in  the  habit  of  warning  such  patients  that  great 
attention  should  be  paid  to  their  throat  and  ears,  by  means  of 
gargles  and  Politzer's  method,  during  the  period  of  utero-ges- 
tation.  It  is  the  proliferous  form  of  inflammation,  and  not 
the  catarrhal,  which  I  have  usually  observed  during  such  cases. 

The  causes  given  by  patients  themselves,  taken  from  my 
note-book,  are  as  follows :  "  Stuffy  sensations  in  the  head ;" 
"  going  in  the  water  very  frequently ; "  "  severe  colds  in  the 
head ; "  "  when  a  child,  the  ears  would  stop  up,  and,  would  not 
hear  well  for  a  few  days."  The  first  manifestation  was  "  a 
roaring  noise  heard  at  night ; "  "  chronic  sore-throat ;  "  "  great 


CAUSES   OF  INFLAMMATION  OF  THE  MIDDLE   EAE.  287 

deal  of  ear-ache;"  "all  the  colds  from  which  I  suffer  are  in 
the  head;"  "  excessive  grief ;  "  "  a  sound  like  that  of  locusts 
was  the  first  indication  of  trouble ; "  "  by  accident  I  discovered 
that  I  could  not  hear  from  one  ear ;  "  "I  have  always  had  a 
great  deal  of  sore-throat;"  "diphtheria;"  "typhoid  fever." 
One  patient  gave  a  graphic  account  of  a  gradual  loss  of 
hearing  from  proliferous  inflammation,  in  the  following  words  : 
"  Ten  years  ago  I  observed  that  I  could  not  hear  the  church- 
bells,  and  in  four  or  five  years  it  began  to  be  difficult  for  me 
to  hear  conversation."  Another  ludicrously  attributed  his 
chronic  catarrh  to  exercise  upon  a  gymnastic  pole.  Another 
was  quite  sure  that  it  resulted  from  great  mental  anxiety. 
These  are  fair  specimens  of  the  causes  assigned  by  the 
patients  or  their  friends  for  cases  of  the  variety  of  aural 
disease  now  under  consideration.  Some  of  them  are  far 
from  being  true  causes,  although  the  most  of  them  may  be 
admitted  as  having  at  least  placed  the  system  in  such  a  con- 
dition that  catarrhal  disease  or  proliferation  of  tissue  was 
likely  to  result.  It  is  undoubtedly  true,  that  any  great  mental 
depression  may  cause  an  attack  of  pharyngitis  in  a  person 
disposed  to  it,  and  that  such  a  long-continued  state  of  mind 
will  make  such  an  affection  incurable. 

"We  may,  perhaps,  sum  up  our  knowledge  of  the  causes  of 
chronic  non-suppurative  disease  of  the  middle  ear,  by  stating 
that  they  are  such  as  dispose  to  inflammation  of  mucous  mem- 
brane. Our  increased  knowledge  of  the  pathology  of  this 
tissue,  will  serve  us  in  good  stead  in  investigating  the  affec- 
tions of  a  part  which  is  thoroughly  lined  by  it. 


CHAPTER    XIII. 

CHRONIC   NONSUPPURATIVE    INFLAMMATION   OF  THE   MIDDLE 
EAR — Continued. 


TREATMENT. 

At  the  beginning  of  the  preceding  chapter  a  table  was 
given,  showing  at  about  what  time  in  the  history  of  their  dis- 
ease the  patients  from  whose  cases  it  was  made  up  consulted 
the  writer.  It  may  be  safely  asserted,  that  the  most  of  these 
persons  never  underwent  any  serious  or  rational  local  treatment 
until  that  time  ;  so  that  we  may  assume  that  the  greater  number 
of  persons  in  the  United  States  who  suffer  from  the  form  of  dis- 
ease under  consideration,  are  in  the  habit  of  waiting  for  a  period 
of  from  five  to  twenty  years  before  they  attempt  to  get  relief. 

We  must  certainly  diminish  the  number  of  these  cases 
before  we  can  hope  for  brilliant  results.  The  neglect  of  aural 
therapeutics  by  the  last  and  the  preceding  generation  now 
recoils  upon  us.  Patients  come  very  late  for  advice  about 
their  ears,  because  they  have  been  taught,  not  by  the  laity, 
but  by  wise  and  skilful  physicians,  that  it  is  not  prudent  to 
meddle  with  the  ear ;  that  they  will  outgrow  its  diseases,  as 
soon  as  their  constitution  is  invigorated ;  if  young  girls,  that, 
when  the  menstrual  function  comes  on,  they  will  be  all  right,  and 
so  forth,  while,  during  this  time  of  delay,  adhesions  between 
the  membrana  tympani  and  the  ossicula,  and  the  walls  of  the 
cavity  of  the  tympanum,  have  been  forming,  and  hypertrophy  of 
the  mucous  membrane  and  atrophy  of  the  tendons  of  the  intra- 
auricular  muscles — in  short,  all  the  changes  that  we  have 
noted  previously — have  occurred. 

In  one  respect  the  treatment  of  the  catarrhal  may  be  fairly 
distinguished  from  that  of  the  proliferous  form.  In  the  ca- 
tarrhal form  we  must  give  a  great  deal  of  attention  to  the  naso- 


CONSTITUTIONAL  TREATMENT.  289 

pharyngeal  space,  while  in  the  other  we  need  to  pay  very  little 
to  it.     Perhaps  we  may  classify  the  treatment  as  follows  : 

1.  Constitutional  and  hygienic.  i 

2.  Local  blood-letting. 

3.  Applications  to  the  naso-pharyngeal  space  (only  appli- 
cable to  the  catarrhal  form  of  the  disease). 

4.  Applications  to  the  Eustachian  tube. 

5.  Applications  to  the  cavity  of  the  tympanum. 

6.  Cutting  operations  upon  the  membrana  tympani  and  the 
ossicula. 

In  the  text-books  of  Wilde  and  Toynbee  (books  that  have 
deservedly  had  a  wide  circulation  in  this  country,  and  have 
done  much  to  call  attention  to  the  ear)  constitutional  treat- 
ment figures  very  largely  in  the  treatment.  The  use  of  mer- 
cury and  iodide  of  potassium  is  strongly  insisted  upon.  "We, 
of  the  present  time,  have  grown  very  skeptical  about  the  con- 
stitutional treatment  of  such  affections  as  chronic  catarrhal, 
and  proliferous  inflammation  of  the  middle  ear.  No  thought- 
ful practitioner  will  attempt  to  disregard  the  general  indica- 
tions of  a  cachexia,  or  of  a  debilitated  system,  in  which  there 
is  chronic  inflammation  of  the  mucous  membrane  of  the  mid- 
dle ear ;  but  the  time  has  probably  gone  by  when  a  person  in 
fair  health,  suffering  from  chronic  aural  catarrh,  and  who  has 
no  constitutional  taint,  will  be  treated  by  alterative  doses  of 
the  bichloride  of  mercury,  followed  by  the  iodide  of  potas- 
sium. Ample  experience  has  shown  that  we  can  do  nothing 
for  these  cases  by  such  a  treatment,  and  I  may  say,  that  it  has 
been  abandoned  in  the  infirmaries  and  hospitals,  where  large 
numbers  of  cases  of  aural  disease  are  seen.  The  constitutional 
symptoms  of  the  earliest  stages  of  the  disease  were  usually 
those  of  a  coryza  or  acute  catarrh,  which  finally  settled  down 
into  an  insidious  and  chronic  process,  when  it  has  become 
impossible  to  trace  the  remote  causes. 

The  causes  of  these  forms  of  disease  suggest  a  kind  of  con- 
stitutional treatment  however,  which  should  never  be  lost  sight 
of.  Everything,  that  will  render  a  patient  more  vigorous,  and 
less  likely  to  take  cold,  will  assist  materially  in  curing  or  alle- 
viating a  chronic  aural  catarrh.  We  shall  thus  find  much  to 
do,  in  the  way  of  correcting  improper  habits  of  life,  in  regard  to 
19 


290  TEEATMENT   OF  THE   PHARYNX. 

bathing,  exercise  in  the  fresh  air,  sleeping  apparel,  and  the 
like.  Hence  the  Turkish  bath,*  sponge-bathing,  walking,  rid- 
ing, boat-rowing,  the  general  application  of  electricity,  iron, 
and  so  forth,  become  prescriptions  which  the  otologist  will  be 
called  upon  to  give  very  frequently,  if  he  properly  appreciates 
cause  and  effect.  It  is  only  against  specific  drugs,  where  there 
is  no  specific  diathesis,  against  a  routine  system  of  prescrib- 
ing a  constitutional  remedy  in  the  vague  hope,  that  it  may  do 
good,  that  I  have  been  speaking. 

The  use  of  leeches  in  some  cases  of  chronic  catarrhal 
inflammations  that  have  sub-acute  tendencies,  is  occasionally 
of  value,  although  they  give  no  such  marked  relief  as  that 
which  is  experienced  in  acute  inflammation.  When  there  are 
marked  symptoms  of  .congestion,  such  as  fulness  and  slight 
pain,  a  leech  may  be  applied  on  the  tragus  once  a  week,  for 
four  or  five  weeks. 

TREATMENT  OF  THE  PHARYNX 

The  treatment  of  the  pharynx  may  be  classified  as  follows  : 

1.  Injections  of  the  naso-pharyngeal  space. 

2.  Gargling. 

3.  Cauterizations. 

Pig.  62. 


Injections  of  the  naso-pharyngeal  cavity  by  means  of  the 
naso-pharyngeal  syringe,  I  have  found  very  valuable  in  the 
treatment  of  chronic  catarrhal  inflammation.  The  solutions  I 
use  are  common  salt,  permanganate  of  potash,  gr.  ^  ad  §  j,  a 
saturated  solution  of  chlorate  of  potash,  tar-water,  etc.  Great 
masses  of  muco-purulent  material  are  often  dislodged  by  this 
treatment,  even  in  cases  where  ordinary  inspection  does  not 
show  that  any  has  collected.  The  nasal  douche  is  very  fre- 
quently used  for  the  purpose  of  cleansing  the  naso-pharyngeal 

*  The  Turkish  bath  is  one  of  the  best  means  of  keeping  the  circulation  so 
equable  that  catarrhs  do  not  readily  occur.  It  is  not  a  good  plan,  however,  to 
allow  the  head  to  be  wet,  during  the  shampooing  process  that  follows  the  hot- 
air  bath,  neither  should  patients  disposed  to  aural  disease,  take  the  cold  plunge 
which  is  often  given  at  the  termination  of  the  whole  process. 


TREATMENT  OF  THE  PHARYNX.  291 

space,  but  it  is  a  means  of  treatment  that  is  attended  with  con- 
siderable danger  to  the  ear,  even  when  all  proper  precautions 
are  taken. 

The  posterior  nares  syringe  is  made  of  hard  rubber.  It  is 
a  very  efficient  and  safe  means  of  cleansing  the  pharj  nx  and 
nostrils.  In  cases  of  acute  inflammation  of  the  pharynx  at- 
tended with  considerable  swelling,  it  should  be  used  with  care, 
or  it  will  abrade  and  irritate  the  mucous  membrane  of  the 
posterior  pharyngeal  wall.  This  abrasion  may  then  lead  to 
an  extension  of  the  inflammation  along  the  tube,  to  the  tym- 
panic cavity.  In  chronic  cases  I  have  never  seen  or  heard  of 
any  harm  being  done  by  the  posterior  nares  syringe. 

Dr.  Warner,  of  Ohio,  uses  an  air-bag  as  the  means  of  forc- 
ing the  fluid  through  the  curved  tube,  and  gives  the  instrument, 
instead  of  the  nasal  douche,  into  the  hands  of  the  patient.  It 
is,  however,  a  rather  dangerous  plan  to  trust  an  operative  or 
mechanical  treatment,  such  as  introducing  an  instrument  be- 
hind the  uvula,  to  a  patient,  where  it  is  possible  to  avoid  it. 

THE   NASAL   DOUCHE. 

The  author  has  published  several  cases  that  illustrate  the 
dangerous  consequences  that  may  result  to  the  ear  from  the 
use  of  the  nasal  douche.  The  appliance  is,  however,  so  con- 
venient of  application,  and  it  is  thought  to  be  so  thorough  in 
its  work  of  cleansing  the  nostrils  and  pharynx,  that  the  pro- 
fession are  very  loth  to  abandon  it.  I  am  of  the  opinion,  how- 
ever, that  its  use  should  be  discountenanced  by  the  profession. 
Various  criticisms  have  been  made  upon  the  published  cases 
of  injury  to  the  ear  from  the  use  of  the  douche,  but  I  believe 
that  they  have  been  fully  met,  and  that  most  of  the  otologists 
on  this  side  of  the  water,  are  agreed  that  the  nasal  douche, 
even  when  employed  with  all  proper  precautions,  has  produced 
serious  aural  symptoms  in  quite  a  large  number  of  cases. 
The  harmful  results  are  probably  due  to  the  entrance  of  a 
large  quantity  of  fluid,  in  a  flood,  as  it  were,  into  the  cavity 
of  the  tympanum  along  the  Eustachian  tube,  and  necessarily 
in  a  direction  contrary  to  the  motion  of  its  ciliated  epithelium. 
The  use  of  the  nasal  douche  was  first,  suggested  by  Pro- 
fessor Theodore  "Weber,  of  Halle,  Germany,  and  is  based  upon 
a  physiological  fact  that  was  first  promulgated  by  Dr.  E.  H. 


292  NASAL  DOUCHE. 

Weber,  of  Leipsic,  in  1847.  This  fact  is,  that  when  one  side 
of  the  nasal  cavity  is  entirely  filled  with  fluid  by  hydro- 
static pressure,  while  the  patient  is  breathing  through  the 
mouth,  the  soft  palate  completely  shuts  off  the  superior 
naso-pharyngeal  space  from  the  mouth,  and  does  not  permit 
any  of  the  fluid  to  pass  downwards.  The  fluid  then  passes 
into  the  opposite  nasal  cavity,  and  escapes  through  the  nos- 
tril. Prof.  Theodore  Weber  suggested  the  use  of  a  cup  to  the 
bottom  of  which  was  attached  a  bit  of  rubber  tubing,  for  the 
purpose  of  taking  advantage  of  this  physiological  principle. 
Such  an  apparatus  is  figured  on  page  124,  and  is  now  very 
much  used  under  the  name  of  Clarke's  aural  douche  for  the 
purpose  of  cleansing  the  meatus  and  stilling  pain  in  the  ear. 
Dr.  J.  L.  W.  Thvdichum  brought  this  apparatus  to  the  notice 
of  the  English-speaking  profession,*  and  made  it  more  con- 
venient, so  that  in  America  it  has  acquired  the  name  of  Dr. 
Thudichum.     It  should,  however,  be  called  Weber's  douche. 

As  early  as  1869,  I  had  found  that  the  nasal  douche  was 
sometimes  a  troublesome  and  dangerous  appliance,  and  I 
added  a  note  to  indicate  this,  in  my  translation  of  Yon  Troltsch 
on  the  Ear  (second  edition,  page  369) ;  but  I  was  not  fully 
convinced  that  it  would  readily  cause  acute  aural  inflamma- 
tion, until  the  following  case  occurred  in  my  practice.  The 
case  has  been  amplified  from  the  first  record  that  appeared,f 
in  order  to  avoid  the  reiteration  of  explanations,  that  the  criti- 
cisms upon  the  case  in  the  Monatsschrift  fur  Ohrenheilkunde, 
and  by  Professor  Elsberg  of  this  city,  compelled  me  to  make. 

Case  of  Otitis  Media  Purulenta,  and  Pyemia,  from  the  Use  of  the  Nasal 
Douche. — On  the  12th  of  December,  1868, 1  was  consulted  by  a  clergyman,  forty- 
nine  years  of  age,  in  regard  to  a  sub-acute  catarrh  of  the  middle  ear,  affecting 
both  sides  of  the  head.  The  history  of  the  patient  was  as  follows :  Some  years 
before,  he  was  attacked  with  what  seemed  to  be  hay  fever,  or  a  form  of  coryza 
attacking  certain  persons  during  the  summer.  This  coryza  became  a  chronic 
catarrhal  inflammation  of  the  naso-pharyngeal  space,  attended  by  the  usual 
symptoms — a  sense  of  stuffiness  of  the  nostrils,  frequent  expectoration  of  glairy 
mucus,  sneezing,  and  so  forth.  For  the  past  two  months  the  patient  has  been  in 
the  daily  habit  of  using  Weber's  nasal  douche,  for  the  purpose  of  cleansing  the 
nostrils  and  of  introducing  remedial  agents  into  them.    He  had  once  before 

*  On  Polypus  in  the  Nose  and  Ozcena.  London,  1869.  Lancet,  Nov.  24, 
1864. 

•j-  Archives  of  Ophthalmology  and  Otology,  Bd.  I. 


NASAL  DOUCHE.  293 

tried  this  means  of  treatment,  but  it  had  caused  so  much  unpleasant  feelings 
in  the  ears  that  he  was  obliged  to  desist  from  employing  it.  A  warmer  solu- 
tion was  always  used  in  the  douche,  and  it  was  employed  under  the  direction 
of  a  physician  who  was  probably  well  aware  of  Dr.  Thudichum's  directions, 
and  took  all  the  precautions  which  he  advises  in  his  pamphlet.  This  fact  is 
mentioned,  because  the  advocates  of  the  douche  claim  that  it  never  does  harm 
when  properly  employed.  Dr.  Thudichum  advises  that  a  solution  of  salt  and 
water,  or  milk  and  water,  but  never  pure  water,  should  be  used,  as  did  Profes- 
sor Weber  some  time  before.  The  patient  was  also  instructed  to  breathe 
through  the  mouth,  and  Dr.  Thudichum  observed  that  very  often  patients 
became  confused,  struggled,  breathed  through  the  nose,  and  defeated  the  plan. 
It  is  during  this  excitement,  that  the  accident  of  entrance  of  fluid  into  the  ear 
seems  usually  to  occur.  For  about  two  weeks  these  unpleasant  sensations  on 
using  the  douche  have  been  again  experienced.  The  patient  complains  of  being 
deaf,  and  of  having  a  full  sensation  in  both  ears,  almost  amounting  to  pain. 
The  membrana  tympani  of  each  side  is  found  to  be  reddened.  An  ordinary 
ticking  watch,  heard  by  a  person  with  normal  hearing  power  about  six  feet,  is 
only  heard  when  placed  in  contact  with  the  auricle  of  each  side.  A  leech  was 
applied  to  each  ear  on  the  tragus,  the  Eustachian  tubes  were  rendered  pervious 
by  means  of  the  catheter  and  Politzer's  method.  In  a  few  days  the  membrana 
tympani  assumed  a  normal  appearance,  and  the  hearing  was  restored  by  means 
of  this  treatment.  The  patient  then  desired  that  an  attempt  should  be  made 
to  relieve  the  trouble  in  the  naso-pharyngeal  region.  The  uvula  and  tonsils 
were  relaxed,  the  whole  mucous  membrane  of  the  upper  pharyngeal  space 
secreted  excessively,  and  the  patient  had  contracted  a  habit  of  constantly 
endeavoring  to  clear  his  nostrils.  Fluids  passed  through  the  left  nostril,  but 
none  through  the  right.  The  Eustachian  catheter,  however,  passed  without 
difficulty.  The  nostrils  were  cleansed  by  means  of  a  nebulizer,  salt  and  water 
being  used  in  it,  after  which  the  parts  were  swabbed  out  with  a  solution  of 
arg.  nit.  gr.  x.  ad  3  j.  The  patient  improved  under  this  treatment  until  Jan. 
28,  when  he  was  for  some  time  exposed  to  the  air  of  a  winter's  day,  with  the 
head  uncovered  (at  the  consecration  of  a  bishop),  when  the  symptoms,  which 
had  been  to  a  certain  extent  relieved,  returned. 

Jan.  31,  a  gelatinous  mass  was  found  plugging  up  the  inferior  meatus  of  the 
right  nostril,  seeming  to  be  attached  to  the  floor  of  the  canal.  Portions  of  this 
were  removed  by  torsion,  at  intervals  of  about  three  days,  until  Saturday,  Feb.  6, 
when  what  seemed  to  be  the  remainder  of  this  growth  was  removed.  The 
patient  left  the  office,  saying  that  his  nostril  was  much  clearer,  and  went  to  Ton- 
kers,  a  city  about  fifteen  miles  by  rail  from  New  York.  There  he  again  used  the 
nasal  douche,  and  again  experienced  a  decidedly  unpleasant  sensation  in  his  ears, 
which,  however,  did  not  amount  to  pain.  On  Sunday  morning  and  evening 
the  patient  performed  his  clerical  duties,  but  with  a  great  sense  of  languor  and 
uneasiness.  On  Sunday  night,  Feb.  7th,  at  about  eleven  o'clock,  he  was  awak- 
ened by  a  severe  pain  in  the  mastoid  region  of  the  right  ear,  which  kept  him 
from  sleep.  I  saw  him  Monday  morning,  at  about  eight  o'clock,  and  noted  the 
following  symptoms :  The  countenance  was  anxious  and  flushed,  the  skin  hot, 
pulse  about  ninety-six,  right  mastoid  region  red  and  sensitive,  right  mem- 
brana tympani  reddened,  watch  only  heard  when  pressed  upon  the  auricle. 
The  patient  was  asked  as  to  the  condition  of  the  left  ear ;  but  he  said  there 


294  NASAL  DOUCHE. 

•was  no  trouble  there.  An  examination  of  the  tragus  and  mastoid  process  failed 
to"  exhibit  any  symptoms  of  inflammation  in  that  ear.  Two  leeches  were 
ordered  to  be  applied  to  the  mastoid  process,  and  the  patient  was  to  take  aq. 
acetat.  amm.  At  five  p.m.,  the  pain  in  the  ear  had  entirely  ceased  after  the 
application  of  the  leeches.  The  patient  was  breathing  hurriedly,  however, 
his  pulse  was  weak  and  frequent — about  ninety-six — and  he  complained  of 
pain  and  tenderness  in  the  abdominal  region.  Morph.  sulph.  gr.  £,  was 
ordered  to  be  taken  pro  re  nata,  and  a  poultice  was  applied  over  the  abdomen. 
Tuesday,  Feb.  7.  The  patient  took  two  powders  of  morphine,  and  passed  quite 
a  comfortable  night.  This  morning  he  complains  of  pain  in  the  forehead,  but 
has  none  in  any  other  x>art  of  the  body.  The  surface  of  the  body  is  dry  and 
hot.  Ordered  aq.  acetat.  ammon.  and  nutritious  diet.  Feb.  8.  Last  night  the 
patient  was  attacked  by  a  severe  pain  and  swelling  of  the  left  foot,  and  at 
about  half-past  seven  A.M.  he  had  a  severe  chill,  lasting  about  fifteen  minutes, 
not  followed  by  sweating.  At  about  this  time  a  discharge  appeared  from  the 
left  ear.  There  has  been  no  pain  experienced  in  this  part.  He  has  not  slept 
well,  and  his  general  appearance  is  bad.  Countenance  anxious.  Breathing 
labored.  Pulse  about  96.  The  left  ankle  and  dorsal  region  of  foot  are  red, 
greatly  swollen,  and  tender.  Left  membrana  tympani  ulcerated  and  discharg- 
ing freely. 

Dr.  Foster  Swift,  of  this  city,  was  called  in  consultation,  and  the  following 
treatment  agreed  upon :  The  foot  was  wrapped  in  an  alkaline  lotion.  Vichy 
water  was  given  ad  libitum,  with  beef-tea  and  wine ;  morphine  pro  re  nata. 
Feb.  9.  Patient  does  not  seem  so  well.  Kespiration  is  hurried.  The  intellect 
is  somewhat  clouded.  Pulse  about  the  same.  Face  of  a  sallow  hue.  The 
stimulants  are  increased,  so  that  he  now  takes  half  an  ounce  of  brandy  in  milk 
punch  every  four  hours,  day  and  night.  Quin.  sulph.  gr.  ii.,  every  four  hours. 
The  left  ear  is  syringed  with  lukewarm  water,  zinc,  sulph.  applied,  and  Polit- 
zer's  method  used  to  inflate  the  drums.  The  patient  is  so  deaf  that  he  only 
hears  when  spoken  to  near  the  ear. 

The  patient  was  treated  in  this  manner,  until  Feb.  22d,  the  brandy  punch 
being  steadily  increased  until  he  was  taking  two  ounces  every  four  hours, 
with  beef-tea,  eggs,  etc.  His  pulse  was  never  over  100,  usually  about  96  ;  the 
skin  had  a  saffron  hue,  and  patient  lay  in  a  doze,  except  when  the  pain  from 
his  foot  kept  him  awake  nearly  the  whole  time. 

Dr.  Qeorge  A.  Peters,  Surgeon  to  the  New  York  Hospital,  was  called  in 
consultation  a  few  days  ago,  in  addition  to  Dr.  Swift  and  myself,  and  to-day 
two  openings  were  made  in  tbe  foot,  one  near  the  internal,  and  one  near  the 
external  malleolus.  Pus  was  evacuated.  The  dorsal  region  of  the  foot  was 
very  much  swollen,  but  no  fluctuation  was  detected.  The  patient's  general 
condition  is  now  better  ;  his  countenance  less  anxious  ;  the  respiration  is  not 
so  hurried.  The  urine  was  several  times  carefully  examined  during  the  treat- 
ment. No  abnormal  condition  was  found,  beyond  an  acid  reaction  early  in  the 
course  of  the  disease.  The  heart  was  also  examined,  and  no  organic  changes 
were  found.  Several  openings  were  made  in  the  foot  from  time  to  time  ; 
but  the  patient  slowly  improved  from  this  time  until  March  16th,  when 
he  was  able  to  sit  up.  The  membrana  tympani  healed,  and  the  hearing  dis- 
tance became  about  one  foot  on  the  right  side,  and  four  to  six  inches  on  the 
left.     Conversation  is  heard  with  ease.     Politzer's  method  has  been  practised 


NASAL  DOUCHE.  295 

every  two  days.  Quinine  and  iron  have  been  taken  in  addition  to  the  stimu- 
lants. The  foot  is  still  swelled,  but  all  the  openings  but  two  have  healed. 
April  4.  The  patient  has  been  going  about  the  house  for  a  week.  Hearing 
power  is  still  further  improved.  A  little  erysipelatous  soreness  of  the  foot 
occurred  last  night.  The  naso-pharyngeal  catarrh  is  completely  gone.  April  7. 
Patient  rode  out  to-day,  and  gets  about  the  house,  employing  himself  in  intel- 
lectual labor.  Tissues  of  the  foot  still  swelled  and  rigid  ;  motions  of  the  ankle- 
joint  unimpaired. 

1873.  I  am  in  the  habit  of  seeing  this  patient  quite  often.     He  is  now  in 
excellent  health,  but  a  very  little  lame  from  the  inflammation  of  the  foot. 

My  friend,  Professor  Elsberg,  of  this  city,  published  a  paper* 
in  which  he  claimed  that  an  analysis  of  the  cases  that  had  been 
published,  of  harm  to  the  ear  from  the  use  of  the  douche,  showed 
that  the  cause  was  uncertain.  Dr.  Elsberg  has  had  a  large  expe- 
rience in  treating  diseases  of  the  pharynx,  and  although  he  has 
prescribed  and  employed  the  douche  in  more  than  1600  cases, 
he  has  seen  none  of  the  results  that  I  have  observed.  I  can  only 
explain  this  by  the  presumption,  that  when  an  accident  to  the 
ear  occurs,  the  patients  are  more  apt  to  consult  a  person  who  is 
in  the  constant  habit  of  treating  aural  disease  than  to  go  on  with 
the  treatment  of  the  nasal  catarrh.  Besides,  as  it  is  believed  by 
many  otologists,  it  is  possible  that  the  douche  sets  up  a  chronic 
inflammation  of  the  tympanic  cavity,  without  any  acute  stage, 
and  thus  the  true  cause  of  an  insidious  chronic  catarrh  is 
passed  over  and  supposed  to  be  an  advance  of  the  naso-pha- 
ryngeal inflammation.  Of  course  it  is  not  believed  by  the 
author  that  the  use  of  the  nasal  douche  will  necessarily  cause 
aural  disease,  but  that  it  is  a  dangerous  means  of  treatment, 
which  should  be  carefully  watched  by  the  practitioner. 

I  append,  from  a  paper  previously  published,  an  analysis  of 
cases  in  which  serious  results  have  occurred.t  Were  it  expe- 
dient to  further  extend  the  discussion  of  this  subject,  I  could 
add  several  more,  for  I  am  constantly  hearing  of  them  from 
my  professional  friends,  and  seeing  them  in  my  own  practice. 
While  preparing  this  chapter  for  the  press,  I  am  treating  daily 
a  patient  suffering  from  suppuration  of  the  middle  ear,  that 
was  caused  by  the  use  of  the  douche.  % 

*  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  p.  77. 
\  L.  c.,  vol.  iii.,  No.  1. 

\  The  famous  Cheselden  mentions  the  fact,  that  syringing  the  nose  when 
the  Eustachian  tube  is  open,  sometimes  causes  deafness. 


296 


NASAL  DOUCHE. 


ANALYSIS  OF  REPORTED  CASES   OF  INJURY  TO  THE  EAR  FROM 
THE  USE   OF   THE   NASAL   DOUCHE. 


Patient. 

Insteuctob*  in 
Use  of  Douche. 

Fluid  Used. 

Ear  Disease  Pro- 
duced. 

Case  I.  Kev.  Dr.  C. 

A  physician. 

A  warm  solution 
of  carbolic  acid. 

Acuta  otitis  media 
suppurativa.  Pyae- 
mia.   Recovery. 

"    2.  Dr.  Frank.* 

Dr.  Prank. 

Cold  water,  which 
he  advises  in  all 

cases. 

Acute  otitis  media. 
Recovery. 

"    3.  Mr.  D. 

Dr.  Eoosa. 

Warm  solution  of 
salt  and  water. 

Perforation  of  both 
menibranse  tympa- 
ni.    Kecovery. 

"    4.  First  of   Dr.  C. 
I.     Pardee's! 
cases. 

A  physician. 

Warm  solution  of 
salt  and  water. 

Otitis  media  suppura- 
tiva. Necrosis  of 
middle  ear.  Per- 
manent deafness. 

"    5.  Second    of  Par- 
dee's}: cases. 
Medical  student. 

A  physician. 

Salt  and  water. 

Acute  otitis  media. 
Recovery. 

"    6.  A  Physician. 

A  physician. 

Unstated. 

Otitis  media  suppura- 
tiva chronica. 

"    t.  Patient  at  Man- 
hattan Eye  and 
Ear  Hospital. 

Unknown. 

Unknown. 

Otitis  media  acuta. 
Recovered: 

"    8.  Mrs.  C. 

Dr.  Mathewson's 
case. 

A  physician. 

Warm  fluids. 

Otitis  media  acuta. 
Recovered. 

"    9.  Dr.    Hackley's! 
case. 

Unknown. 

Warm  salt  water. 

Otitis  media  suppura- 
tiva chronica,  su- 
pervening on  old 
perforations. 

"  10.  Dr.    Piffard's§ 

case. 

Unknown. 

Warm  fluids. 

Otitis  media  acuta. 
Recovery. 

"11.  Judge' . 

A  physician. 

Unknown. 

"  Deafness."  Recov- 
ery. 

"  12.  Dr.    Loring'sll 
case. 

A  physician. 

Warm  fluid. 

Otitis  media  suppura- 
tiva chronica. 

"  13.  Physician! 

Dr.Mathewson's 
second  case. 

A  physician. 

Unstated. 

Otitis  media  acuta. 
Recovery. 

"  14  Physician.^ 

Dr.Mathewson's 
third  case. 

A  physician. 

Unstated. 

Otitis  media  subacuta. 

"  15.  Physician. 

A  physician. 

Warm  salt  water. 

Fainting  and  otitis 
media  catarrhalis. 

"  16.  Dr.  G.  D .  Pome- 

roy's  case.! 

Dr.  Pomeroy. 

Warm  salt  water. 

Otitis  media  suppura- 
tiva. 

*  The  instructor  is  given  in  order  to  meet  the  point  made  by  the  advocates  of  the  douche, 
that  no  harm  occurs  when  it  is  properly  employed. 

t  Archivfiir  Ohrenheilkunde,  Bd.  V.,  p.  202. 

t  The  Medical  Gazette,  vol.  vi.,  No.  23.    Medical  Record,  Feb.  1,  1870. 

§  Reported  by  Dr.  Pardee,  1.  c.  II  Verbal  report  to  writer. 

!  Reported  in  Archives  for  Ophthalmology  and  Otology,  vol.  iii.,  No.  2. 

Dr.  Pardee,  in  his  paper  in  the  Medical  Gazette,  claims  that  the  douche  is  an  inefficient,  as 
well  as  dangerous  instrument.  He  does  not  think  that  the  conformation  of  the  nasal  pas- 
sages allows  of  their  being  cleansed  by  such  a  flood  of  water  as  comes  from  the  douche. 


geuber's  method.  297 

GRUBEE'S  METHOD. 

Graber  adopts  a  method  of  cleansing  and  medicating  the 
naso-pharyngeal  space,  for  which  he  claims  superiority  over  the 
naso-pharyngeal  syringe  and  the  nasal  douche.  Dr.  Gruber 
also  claims  that  his  method  of  treatment  was  promulgated  a 
year  before  the  nasal  douche  was  introduced  to  the  profession — 
that  is,  in  1863,  at  a  meeting  of  the  medical  profession  in 
Vienna.  But  Gruber  spoke  of  his  method  only  with  reference 
to  aural  disease,  while  Weber's  nasal  douche  was  recommended 
as  a  means  of  treating  the  nares.  Gruber's  method  consists  in 
the  use  of  a  two-ounce  hard  rubber  aural  syringe,  the  nozzle  of 
which  is  well  rounded  off,  in  the  following  way  :  The  syringe 
is  filled  with  the  fluid  to  be  injected  and  placed  in  one  nostril. 
The  fluid  is  then  forced  with  more  or  less  vigor  into  the  nos- 
tril, the  other  being  closed  with  the  finger,  if  the  operator 
desires  to  inject  the  Eustachian  tubes,  but  left  open  if  the 
intention  be  to  simply  inject  the  naso-pharyngeal  space.  "  In 
the  force  with  which  I  empty  the  syringe,  in  the  more  or  less 
perfect  closure  of  the  other  nasal  meatus,  are  found  the  fac- 
tors which  more  or  less  favor  the  entrance  of  fluids  through 
the  tubes.  The  latter  effect  may  also  be  increased,  after  the 
syringe  is  removed,  by  causing  the  patient  to  perform  the 
Valsalvian  experiment."  * 

Gruber  believes  that  it  is  the  root  of  the  tongue,  as  well  as 
the  soft  palate,  that  by  instinctive  contraction  and  lifting  up- 
wards shuts  off  the  superior  from  the  inferior  pharyngeal 
space,  and  prevents  fluids  injected  by  the  nasal  douche  or  by 
his  method  from  passing  downward.  This  statement  is  proved 
by  the  fact  that  when  the  soft  palate  is  destroyed  by  ulcera- 
tion, the  fluid  may  be  made  to  pass  out  of  the  other  nostril, 
as  well  as  if  the  palate  were  sound. 

Gruber  deprecates  much  instruction  to  the  patient  as  to 
how  he  shall  breathe  or  hold  his  palate  during  the  injection 
of  the  fluid,  but  he  prefers  to  leave  him  to  his  own  instincts. 
A  fluid  should  be  used  which  will  do  no  harm  if  some  of  it 
pass  into  the  stomach. 

*  Monatsschrift  fur  Ohrenlieilkunde,  Jahrgang  VI.,  No.  4. 


298 


GEUBEE  ON  THE  NASAL  DOUCHE. 


Dr.  Gruber  fully  corroborates  my  views  that  the  harmful 
effects  of  the  nasal  douche  are  due  to  the  entrance  of  the 
fluid  into  the  middle  ear,  and  he  shows  that  however  proper 
it  may  be  to  intentionally,  inject  fluid  in  small  quantities  into  a 
diseased  cavity  of  the  tympanum,  it  is  manifestly  incorrect  to 
force  it  into  an  ear  that  was  previously  healthy,  with  no  restric- 
tion as  to  quantity,  as  is  done  in  the  use  of  the  nasal  douche. 

"  The  current  from  the  nasal  douche  is  continuous,  even 
when  the  cavity  of  the  tympanum  is  already  full ;  the  fluid  in 
the  pharynx  attempts  more  and  more  to  enter  into  the  middle 
ear,  and  when  the  pressure  is  very  great,  rupture  of  the  mem- 
brana  tympani  may  occur.  I  have  often  seen  ecchymoses 
on  the  membrana  tympani,  that  were  caused  by  the  nasal 
douche."  * 


Fig.  63. 


Nebulizer  for  Pharynx. 

I  am  very  glad  to  have  the  views  which  I  first  brought 
before  the  profession,  thus  endorsed  by  so  high  authority  as 
Professor  Gruber.  It  is  to  be  hoped  that  the  method  of 
anterior  syringing,  and  the  use  of  the  posterior  nares  syringe, 
may  finally  supplant  the  nasal  douche. 

The  solution  that  may  be  used  with  benefit  as  gargles  are, 
of  course,  very  numerous.  The  gargle  that  I  most  frequently 
prescribe  is  a  saturated  solution  of  chlorate  of  potash.  Where 
there  is  much  granular  pharyngitis,  a  gargle  containing  iodine, 
will  probably  be  more  efficacious.  I  am  in  the  habit  of  ad- 
vising patients  suffering  from  chronic  disease  of  the  middle 
ear,  suppurative  or  non-suppurative,  to  use  a  gargle  of  cold 


*  Gruber,  1.  c,  No.  8. 


CAUTEBIZATION  OF  MOUTH  OF  EUSTACHIAN  TUBE. 


299 


water,  by  Von  Troltsch's  method,  as  long  as  they  live.  The 
gymnastic  exercise  of  the  muscles  of  the  Eustachian  tube,  is 
by  no  means  an  unimportant  means  of  treatment. 

Gargling  is  a  very  efficient  means  of  cleansing  the  pharynx, 
if  it  be  performed  in  the  manner  advised  by  Yon  Troltsch. 
The  fluid  is  held  in  the  back  part  of  the  mouth,  the  head 
being  thrown  well  back,  the  nostrils  closed  by  the  fingers,  and 
then  the  motion  of  swallowing  is  performed.  With  a  little 
practice,  the  patient  will  become  very  proficient  in  this  method. 
Those  who  are  skeptical  as  to  the  virtue  of  gargling,  and  who 
claim  that  the  process  does  not  cause  the  fluid  to  wash  the 
pharynx,  will  be  convinced  of  the  contrary  by  the  following 
simple  experiment :  Let  the  posterior  wall  of  the  pharynx 
be  painted  with  the  tincture  of  iodine,  and  then  a  gargle  of 
starch- water  be  used  in  the  manner  described,  and  the  charac- 
teristic reaction  will  be  found  in  the  ejected  fluid. 


Fig.  64. 


Pomeroy 's  Faucial  Catheter. 


Cauterization  of  the  mouths  of  the  Eustachian  tubes,  and 
of  the  posterior  pharyngeal  wall,  is  of  great  value  in  the  treat- 
ment of  catarrh  of  the  middle  ear.  Nitrate  of  silver  in  solutions 
of  from  20  to  100  grains  to  the  ounce  of  water,  is  the  agent 
chiefly  to  be  employed.  It  should  always  be  used  by  a  nebu- 
lizing apparatus,  in  preference  to  a  probang,  although  where 
the  granulations  are  well  defined,  the  individual  elevations 
may  be  pencilled  with  the  solutions. 

These  applications  are  not  very  unpleasant,  and  they  are 


300  FAUCIAL  CATHETEKS. 

certainly  very  efficient  in  diminishing  secretion,  and  in  chang- 
ing the  character  of  tissue.  The  use  of  the  solid  stick  is  very 
unpleasant  to  the  patient,  and  is,  I  think,  to  be  avoided. 
Dr.  O.  D.  Poineroy,  of  this  city,  who  has  done  much  to  intro- 
duce the  nitrate  of  silver  treatment  of  the  pharynx  in  aural 
disease,  uses  a  peculiar  instrument  for  making  applications  to 
the  mouth  of  the  tube,  and  for  inflating  the  cavity  of  the  tym- 
panum.* Although  Dr.  Poineroy  names  his  apparatus  a  fau- 
cial  catheter,  I  am  inclined  to  think  that  its  chief  value  is  as  a 
means  of  making  applications  to  the  mouth  of  the  tube,  and 
not  of  inflating  the  middle  ear. 

The  instrument  consists  of  a  hard  rubber  tube,  seven  and  a 
half  inches  in  length.  Its  breadth  at  its  proximal  extremity  is 
one-fourth  of  an  inch,  but  it  lessens  towards  the  beak,  which 
is  a  little  more  than  one-eighth  of  an  inch  in  thickness.  The 
proximal  extremity  has  a  lip  for  the  adjustment  of  a  rubber 
tube.  At  about  an  inch  and  a  half  from  this  is  a  perpendicu- 
lar guide,  placed  in  an  opposite  direction  to  the  beak  of  the 
instrument.  This  guide  serves  to  show  the  direction  of  the 
beak  of  the  instrument  when  in  position.  The  curved  portion 
of  the  tube  is  one  inch  and  three-sixteenths  in  length.  At  a 
line  or  a  line  and  a  half  from  the  end  of  the  beak,  is  an  aper- 
ture for  the  injection  of  air  or  fluids  of  the  caliber  of  a 
No.  1  Bowman's  probe.  This  aperture  is  so  placed,  as  seen 
in  the  cut  on  the  previous  page,  as  to  cause  the  air  or  fluid  to 
be  thrown  from  the  operator,  or  in  the  axis  of  the  Eustachian 
tube.  Air  is  injected  into  the  mouth  of  the  tube  by  simply 
compressing  the  air-bag,  when  the  catheter  is  in  position. 
Fluids,  of  which  a  drop  or  two  are  sucked  up  at  each  applica- 
tion into  the  beak  of  the  instrument,  are  forced  into  the  tube, 
in  the  form  of  a  fine  spray. 

Dr.  Poineroy  thinks  that  the  use  of  this  instrument  is  ordi- 
narily simpler  than  the  employment  of  Politzer's  method ;  but 
in  this  view  I  cannot  coincide — and  as  a  catheter,  I  hardly  think 
it  will  take  the  place  of  an  instrument  introduced  through  the 
nose.  The  verdict  of  the  profession  has  hitherto  been  for  the 
method  of  Cleland,  as  against  that  of  Guyot,  and  none  of  the 

*  Transactions  of  American  Otological  Society,  1872. 


TREATMENT  OP  EUSTACHIAN  TUBE.  301 

faucial  instruments  have,  as  yet,  reversed  this  judgment.  The 
faucial  catheter  of  Dr.  Cutter,*  ingenious  as  it  is,  will  hardly 
supersede  the  catheter  in  ordinary  use,  which  is,  as  has  been 
demonstrated,  an  efficient  instrument,  and  one  that  in  ninety- 
nine  cases  out  of  a  hundred  is  readily  introduced,  and  with  no 
"  guess-work,"  as  has  been  said,  but  with  an  exact  knowledge 
of  its  position. 

Solutions  of  sulphate  of  zinc,  of  alum,  sesquichloride  of 
iron,  and  so  on,  hi  weak  solutions,  may  be  used  with  advan- 
tage by  the  patient  himself  during  the  treatment  of  naso- 
pharyngeal inflammation.  They  are  most  efficient  when  used 
in  one  of  the  nebulizers  that  are  now  so  largely  employed  in 
the  treatment  of  the  throat. — (See  Fig.  63.) 

THE  TREATMENT  OF  THE  EUSTACHIAN  TUBE. 

Among  the  means  employed  in  the  treatment  of  the  Eus- 
tachian tube,  the  use  of  the  Eustachian  catheter  stands  pre- 
eminent. It  is  difficult  to  say  whether  we  treat  the  tube 
or  the  cavity  to  which  it  leads  by  the  means  of  this  in- 
strument. We  may  often  very  much  improve  the  hearing 
power  of  a  patient  by  the  introduction  of  the  instrument  be- 
tween the  lips  of  the  tube,  even  when  no  air,  vapor,  or  fluid, 
is  passed  through  it.  After  such  a  procedure  it  is  much 
more  easy  to  inflate  the  ear  by  Politzer's  method.  Some  have 
rather  hastily,  as  it  seems  to  me,  concluded  that  all,  or  the 
greater  part  of  the  effect  produced  by  the  catheter,  might  be 
had  by  applications  to  the  mouth  of  the  tube,  and  have  dis- 
carded the  catheter  ;  but  I  become  more  and  more  convinced 
after  ten  years  of  pretty  steady  experience  in  its  use,  that  the 
Eustachian  catheter  is  essential  in  the  treatment  of  chronic 
non-suppurative  inflammation  of  the  middle  ear.  -The  agents 
to  be  introduced  through  it  are  : 

Atmospheric  air, 

Vapors, 

Fluids, 

Bougies, 

Electricity. 

*  American  Journal  of  the  Medical  Sciences,  April,  1872. 


302  ATMOSPHERIC  AIR — VAPORS. 

I  have  placed  common  atmospheric  air  first,  because  I  re- 
gard it  as  the  most  important  of  the  agents  to  be  employed. 
It  is,  however,  not  so  efficient  in  chronic  as  in  sub-acute  or 
acute  aural  catarrh,  where  its  effects  are  almost  magical.  In 
fact,  it  may  be  claimed,  that  there  are  no  idiopathic  affections 
for  which  relief  is  so  immediately  obtained  as  acute  catarrhal 
inflammation  of  the  middle  ear,  where  inflations  of  the  tympanic 
cavity  with  simple  air  are  often  sufficient  to  cause  a  patient,  for 
whom  the  world  of  sound  is  again  open,  to  shed  tears  of  joy. 

Among  the  vapors  employed,  I  attach  most  importance  to 
the  vapor  of  water — steam — an  old  remedy,  but  one  which  had 
most  undeservedly  fallen  into  disuse  in  this  country,  until  it 
was  again  employed  by  myself. 

Br  C.  I.  Pardee*  has  published  a  paper,  in  which  he  has 
carefully  noted  the  results  of  six  cases  of  the  most  obdurate 
variety  of  non-suppurative  disease  of  the  middle-ear,  and  in  all 
of  these  there  was  marked  improvement,  both  in  the  hearing 
distance  and  in  respect  to  the  tinnitus  aurium,  by  the  use 
of  steam  through  the  catheter.  Dr.  Pardee  deduced  from  his 
cases  the  practical  lesson,  that  in  the  treatment  of  the  disease 
of  the  tympanic  cavity,  its  condition  of  moisture  or  dryness 
should  be  considered,  and  that  when  dryness  exists,  our  thera- 
peutic efforts  should  tend  to  re-establish  the  normal  secretion. 

I  am  in  full  accord  with  Dr.  Pardee's  proposition,  and 
I  do  not  therefore  use  the  vapor  of  water  in  the  strictly 
catarrhal  cases,  but  in  the  proliferous  inflammation,  where 
adhesions  exist,  with  rigidity  and  hypertrophy  of  the  mucous 
membrane. 

The  apparatus  required  for  the  injection  of  steam  into  the 
cavity  of  the  tympanum,  consists  of  the  following  appliances : 

1.  An  apparatus  for  generating  the  vapor. 

A  nickel-plated  copper  flask  is  the  best  for  this  purpose, 
although  a  glass  flask  used  over  a  sand-bath  will  do  very  well. 
The  only  objection  to  the  glass  flask  is,  that  the  flame  may 
leap  beyond  the  level  of  the  water  in  the  flask,  and  break  it, 
as  has  often  occurred  to  me.  Two  glass  tubes  are  placed  in 
the  cork,  and  a  very  minute  opening  for  the  escape  of  steam. 

*  Transactions  cf  the  American  Otological  Society,  1870. 


STEAM.  303 

A  piece  of  flexible  rubber  tubing  is  placed  over  each  of  the 
glass  tubes.  In  the  free  end  of  one  of  the  tubes  is  a  nozzle 
adapted  to  the  Eustachian  catheter ;  in  the  other  a  tip  adapted 
to  an  ordinary  air-bag. 

2.  A  hard-rubber  Eustachian  catheter.  A  metallic  instru- 
ment cannot  be  used,  on  account  of  its  becoming  too  hot  to  be 
borne.     Many  practitioners  keep  the  catheter  in  place  by  a 

Fig.  fi5. 


Apparatus  f oi-  Steaming  the  Middle  Ear. 


holder ;  but  I  always  employ  my  fingers  for  that  purpose.  Dr. 
Pardee  gives  the  following  account  of  the  method  of  forcing 
the  steam  into  the  catheter,  a  method  which  I  have  found 
important  to  be  observed  in  detail.  The  steam  may  be  gener- 
ated by  a  gas-burner,  as  depicted  in  the  cut,  or  by  an  alcohol 
lamp.     I  prefer  the  former. 

"  The  catheter  should  be  placed  in  the  mouth  of  the  Eusta- 
chian tube,  and  retained  in  position  by  the  catheter-holder ; 
then  the  small  nozzle  of  the  steam  apparatus  being  in  the 
outer  end  of  the  catheter,  steam  can  be  forced  to  the  middle 
ear  by  sharp  pressure  on  the  air-bag.     If  the  pressure  on  the 


304:  USE  OF  FLUIDS  THEOUGH  THE  TUBE. 

air-bag  is  slow,  the  prolonged  contact  of  the  steam  is  likely  to 
be  unpleasantly  felt  by  the  patient,  and  there  is  some  danger 
that  it  may  escape  into  the  pharynx  and  provoke  inflamma- 
tion there.  On  the  other  hand,  if  it  be  applied  by  sudden, 
sharp  pressure,  and  the  nozzle  removed  from  the  catheter  after 
each  puff,  no  inconvenience  is  ever  felt,  and  there  is  no  possi- 
ble danger  of  exciting  inflammatory  action  in  the  pharynx." 

FLUIDS. 

After  all  the  experiments  to  determine  whether  fluids 
forced  into  the  tube  through  the  catheter  actually  reach 
the  cavity  of  the  tympanum,  it  is,  I  believe,  pretty  conclu- 
sively settled  that  they  do,  and  they  may  have  a  decided  effect 
upon  the  lining  membrane  of  this  part. 

Wreden's  experiments  make  it  somewhat  doubtful,  whether 
a  few  drops  of  fluid,  injected  through  the  Eustachian  catheter, 
actually  reach  the  cavity  of  the  tympanum.  All  the  experi- 
ments that  have  been  made  agree,  however,  in  one  fact,  that 
where  a  large  quantity  of  fluid  is  injected  en  masse,  it  reaches 
the  cavity  of  the  tympanum.  The  usual  method  of  injecting 
a  fluid  into  the  mouth  or  caliber  of  the  Eustachian  tube  is  the 
following :  The  Eustachian  catheter  is  introduced  in  the  usual 
way,  the  patient  having  previously  taken  a  little  water  in  his 
mouth.  A  drop  or  two  of  the  fluid  to  be  injected  is  then 
placed  in  the  nozzle  of  the  catheter,  and  at  the  moment  the 
patient  swallows,  it  is  forced  into  the  tube  by  an  air-bag. 

Dr.  F.  E.  Weber,  of  Berlin,  has  invented  an  instrument  for 
spraying  the  tube  and  the  tympanic  cavity.  He  calls  his 
apparatus  the  "  pharmaco-koniantron."  It  consists  essen- 
tially of  a  long  and  flexible  Eustachian  catheter,  which  is 
passed  into  the  tube  as  far  as  the  junction  of  the  cartilaginous 
with  the  osseous  portion.  It  is  perforated  laterally  about 
l-|mm.  from  its  beak,  and  it  is  introduced  through  an  ordinary 
metallic  catheter.  The  fluid  is  forced  through  the  lateral 
opening  in  the  form  of  spray,  by  means  of  an  air-bag  attached 
laterally  to  the  tube  of  a  small  syringe.  The  fluid  to  be  used 
is  first  driven  by  the  syringe  into  the  nozzle  of  the  catheter, 
and  then  forced  forward  by  the  air-bag. 


USE   OP  FLUIDS  THEOUGH  THE  TUBE.  305 

As  lias  been  intimated,  Dr.  Wreden*  does  not  believe,  that 
drops  of  fluid  injected  in  the  manner  that  has  been  described 
through  a  tubal  catheter,  reach  the  cavity  of  the  tympanum, 
but  that  they  pass  only  to  the  osseous  part  of  the  tube.  He 
does  not  deny  that  injections  en  masse  will  reach  the  cavity  of 
the  tympanum,  but  he  thinks  such  injections  dangerous. 

"Wreden  advises  the  use  of  the  tympanic  catheter — that  is, 
a  catheter  that  passes  beyond  the  isthmus  of  the  tube,  as  a 
vehicle  for  introducing  drops  of  fluid  into  the  middle  ear. 
After  the  tubal  catheter,  through  which  the  tympanic  one  is 
passed,  is  in  position  and  fastened  by  means  of  a  forehead 
band,  and  the  permeability  of  the  tube  has  been  ascertained 
by  the  use  of  a  probe  1.4mm.  in  thickness,  the  operator  drops 
five  drops  of  the  solution  to  be  used  upon  a  watch  crystal  or 
other  convenient  receptacle,  draws  it  up  into  the  catheter  and 
inserts  the  instrument  as  far  as  the  tympanic  orifice  of  the  tube. 
The  drops  are  then  forced  into  the  middle  ear  by  the  mouth. 
Sensations  of  fulness  in  the  ear,  and  an  increase  of  the  impair- 
ment of  hearing,  usually  occur,  but  they  pass  off  in  from  6  to  12 
hours.     In  about  48  hours  the  beneficial  effect  should  be  seen. 

Wreden  uses  the  following  named  agents  through  the  tym- 
panic catheter,  and  he  insists  that  the  maximal  doses  should 
not  be  exceeded,  lest  acute  inflammation  be  excited. 

1.  Fused  caustic  potash,  one-quarter  to  one-half,  grain  to 
the  ounce  of  water. 

2.  Liquor  potassse,  three  to  five  drops  to  the  ounce  of 
water. 

3.  Concentrated  acetic  acid,  two  to  three  grains  to  the 
ounce  of  water. 

4.  Pure  iodine,  one-eighth  to  one-quarter  of  a  grain  to  the 
ounce  of  a  half-per  cent,  solution  of  iodine. 

5.  Corrosive  sublimate  of  mercury,  one-twelfth  to  one- 
eighth  of  a  grain  to  the  ounce  of  water. 

6.  Nitrate  of  silver,  one-quarter  to  one  grain  to  the  ounce 
of  water. 

7.  Sulphate  of  copper,  one-quarter  to  one  grain  to  the 
ounce. 

*  Separat-abdruck  aus  der  St.  Petersburger  mediciniscbeD  Zeitscbrift  N.  F. 
Bd.  I.    1871. 

20 


306  FLUIDS  THEOUGH  EUSTACHIAN  TUBE. 

8.  Sulphate  of  zinc,  one  to  two  grains  to  the  ounce. 

9.  Iodide  of  potassium,  two  to  five  grains  to  the  ounce. 

10.  Sulphate  of  atropine,  one-half  to  one  grain  to  the 
drachm  of  water. 

11.  Hydrate  of  chloral,  one  to  two  grains  to  the  ounce  of 
water. 

Wreden  uses  these  agents  through  the  tympanic  catheter, 
chiefly  in  the  proliferous  form  of  inflammation  of  the  middle 
ear.  These  injections  are  made  every  third  or  fourth  day,  for 
from  fifteen  to  twenty  days,  and  although  it  is  not  claimed 
that  the  results  are  brilliant,  they  are  well  worthy  of  a  trial 
where  all  the  ordinary  means  by  a  tubal  catheter  have  failed. 

In  chronic  catarrhal  inflammation  the  agents  named  last 
on  the  list  are  also  used,  but  the  caustic  applications  are 
only  applied  to  the  cases  of  proliferous  inflammation — the 
cases  classed  under  the  head  of  sclerosis  by  Yan  Troltseh. 

Kramer  was  perhaps  the  first  to  use  the  tympanic  cathe- 
ter to  any  great  extent,  and  his  instrument  is  essentially  the 
one  that  Wreden  employs.  It  is  a  hard-rubber  catheter,  made 
long  enough  to  reach  the  tympanic  orifice,  and  is  passed  into 
the  tube  through  an  ordinary  tubal  catheter. 

Bishop,  of  London,  invented  a  nebulizer  for  the  faucial 
mouth  of  the  Eustachian  tube  ;  but  it  was  a  very  inconvenient 
instrument,  and  never  came  into  general  use. 

Dr.  C.  E.  Hackley's  instrument  will  be  found  a  more  effi- 
cient means  of  spraying  the  tube.  Dr.  Hackley's  apparatus 
consists  of  an  air-bag,  an  Eustachian  catheter,  with  a  hard- 
rubber  nozzle  to  fit  in  its  mouth,  a  piece  of  rubber  tubing,  and 
a  hypodermic  syringe.* 

"  The  nozzle  of  the  air-bag  is  inserted  into  one  end  of  the 
rubber  tube,  the  tip  to  fit  in  the  catheter  being  placed  in  the 
other  end.  The  hypodermic  syringe  is  filled  with  the  liquid 
to  be  employed,  then  its  point  passed  through  the  tube  and 
out  through  the  caliber  of  the  hard-rubber  tip  for  the  catheter, 
as  shown  in  the  cut." 

"  The  mouth  of  the  Eustachian  catheter  B  being  fitted  over 
the  hard-rubber  tip  A,  and  held  there,  if  sudden  pressure  is 

*  Medical  Record,  No.  134. 


EUSTACHIAN  NEBULIZER. 


307 


made  on  the  air-bag,  while  the  piston  of  the  syringe  is  forced 
home,  the  liquid  will  be  thrown  through  the  catheter  in  the 
form  of  spray. 

"  In  using  this  apparatus  for  the  treatment  of  diseases  of 
the  ear,  the  catheter  should  be  carefully  introduced  through 
the  nose,  and  placed  in  position.  Then,  while  the  diagnostic 
tube  is  placed  in  the  ear,  the  hard-rubber  tip  should  be  in- 
serted in  the  catheter,  and  air  alone  forced  through  to  deter- 


Fig.  66. 


Hockley's  Eustachian  Nebulizer. 

mine  whether  the  catheter  be  properly  in  position.  If  found 
to  be  so,  the  piston  may  be  pressed  on  at  the  same  time  that 
air  is  forced  through.  During  this  experiment  the  catheter 
may  be  held  in  position  by  clamps  for  that  purpose,  or  may 
be  held  by  the  fore  and  middle  fingers  of  the  left  hand,  while 
the  thumb  of  the  same  hand  presses  on  the  piston,  the  other 
hand  being  used  to  work  the  air-bag." 

It  is  well  to  have  a  small  round  opening  made  in  the  air- 


308  politzer's  method. 

bag,  as  at  C ;  while  the  air  is  being  forced  out  this  may  be 
closed  by  the  finger,  which  then  being  removed,  the  air-bag 
quickly  fills  again. 

It  may  be  said  in  general  terms  that  the  use  of  spray  of 
astringent  fluids  to  the  Eustachian  tube,  is  chiefly  of  value  in 
those  cases  in  which  the  evidences  of  catarrh,  or  increased 
secretion,  are  strongly  marked,  while  fluids  are  to  be  em- 
ployed in  the  tympanic  cavity,  when  there  is  marked  evi- 
dence of  the  predominance  of  the  proliferous  form  of  disease. 

The  injections  of  simple  air,  or  of  medicated  vapors,  in 
what  may  be  called  the  mild  cases  of  catarrhal  inflammation, 
will  be  found  quite  as  efficacious  as  fluids  or  spray.  As  has 
been  already  mentioned,  steam  is  chiefly  applicable  to  cases 
of  proliferous  inflammation. 

I  am  in  the  habit  of  employing  Politzer's  method  of  inflat- 
ing the  drum-cavity,  immediately  after  the  use  of  the  Eusta- 
chian catheter,  in  all  cases  of  chronic  disease  of  the  middle 
ear,  but  I  cannot  believe  that  it  is  a  substitute  for  the  catheter. 
It  is  very  often  found  that  no  impression  can  be  made  upon 
the  tube  or  middle  ears  by  the  use  of  Politzer's  method  alone, 
but  after  the  catheter  has  been  once  passed  into  the  mouth  of 
the  tube,  and  some  muscular  spasm  set  up  in  the  abductor 
and  dilator  of  the  opening,  that  this  means  of  treatment  be- 
comes effectual  at  once.  It  is  not  well,  however,  to  place  the 
air-bag  in  the  hands  of  the  patient  and  advise  hiin  to  use  it. 
Such  advice  will  usually  be  over -regarded,  and,  instead  of 
inflating  the  ears  every  other  day,  it  will  be  done  every  horn' 
perhaps.  Besides,  patients  are  often  very  unsuccessful  in 
their  attempts  to  drive  air  into  the  ears.  Of  course  there  are 
cases  in  which  this  system  of  self-treatrnent  must  be  adopted, 
or  none  at  all  can  be  undertaken ;  but  physicians  who  treat 
aural  disease  soon  learn  that,  if  they  wish  to  achieve  the  best 
results,  the  treatment  must  be  carried  on  by  the  medical 
adviser  himself,  and  not  be  delegated  to  lay  authority. 

Some  years  since,  I  began  to  inject  vapors  into  the  ear  by 
means  of  a  simple  apparatus*  which  is  represented  on  the 
next   page.      The   apparatus   consists  of  a  hollow  bulb   of 

*  American  Journal  of  the  Medical  Sciences,  vol.  liii.,  p.  62. 


USE  OP  VAPOES  BY  rOLITZER  S  METHOD. 


309 


hard  rubber,  which  is  attached  by  a  bit  of  rubber  tubing  to 
the  air-bag  used  in  Politzer's  method.  Any  fluid  that  is  readily 
vaporized  is  placed  upon  a  sponge  contained  in  the  bulb,  and 
on  practising  inflation  of  the  ear,  the  vapor  is  forced  into  the 
Eustachian  tube  and  the  cavity  of  the  tympanum.  The  tinc- 
ture of  iodine  and  chloroform  are  the  agents  I  chiefly  employ. 
Dr.  J.  S.  Prout,  of  Brooklyn,  taught  me  the  value  of  chloro- 
form as  a  means  of  diagnosticating  closure  of  the  tube.  This 
vapor  will  penetrate  the  ear  when  air  or  iodine  are  not  per- 
ceived, and  when  all  attempts  at  inflation  with  air  have  failed, 
or,  as  should  be  said,  when  the  patients  experience  no  sensa- 
tion in  the  ears  from  the  use  of  air  through  the  catheter,  or  by 
Politzer's  method.    Great  caution  should  be  used  in  employ- 


Fig.  67. 


Apparatus  for  Injecting  Vapors  into  the  Nasal'  Passages. 


ing  the  chloroform  ;  that  is,  but  a  few  drops  should  be  used, 
or  the  most  intense  pain  will  be  caused.  I  have  seen  patients 
jump  from  the  chair  in  surprise  and  pain,  after  one  careful 
inflation,  when  only  two  or  three  drops  were  upon  the  little 
sponge  in  the  bulb,  and  this,  after  attempts  to  cause  a  sensa- 
tion in  the  ears  with  common  air  had  utterly  failed.  The  use 
of  chloroform  vapor  is  certainly  a  very  valuable  diagnostic 
means,  although  I  am  not  so  certain  of  its  therapeutic  value. 
The  hollow  bulb   was  recommended   as   an  inhaler  by  Dr. 


310  TJSE  OF  VAPORS  by  polttzer's  method. 

Buttles  of  this  city ;  but  the  attachment  to  Politzer's  appa- 
ratus was  first  made  by  myself.  The  vapor  of  iodine  is  very 
useful  in  many  cases  of  naso-pharyngeal  catarrh,  and  may 
be  used  by  means  of  the  inhaler  that  has  been  described,  or 
by  means  of  the  simple  apparatus  that  is  represented  on  the 
previous  page.  It  is  very  much  employed  by  my  colleague, 
Dr.  Andrew  H.  Smith,  at  the  Manhattan  Eye  and  Ear  Hospi- 
tal. It  consists  of  a  simple  glass  bottle,  whose  cork  is  pierced 
with  two  holes,  in  each  of  which  is  a  bent  tube  ;  one  of  these,  or, 
reaches  nearly  to  the  bottom,  the  other  simply  passes  through 
the  cork.  The  latter  tube  has  india-rubber  nose-piece,  such 
as  is  used  in  the  ordinary  nursing  bottles.  The  other  is  con- 
nected to  an  air-bag,  b,  by  which  the  vapor  of  the  tincture  of 
iodine  is  forced  into  the  nostrils  for  three  or  four  minutes. 

Fig.  68. 


Air-bag,  with  Inhaler  Attachment. 

Dr.  Peter  Allen,  of  London,  substitutes  a  nasal  pad,  which 
is  pressed  against  the  opening  into  the  nostrils,  for  the  tube 
which,  when  Politzer's  method  is  employed,  is  inserted  into 
one  nasal  meatus.  These  air-pads  are  mounted  on  a  strong 
piece  of  covered  cotton  wire,  and  they  can  be  brought  together 
or  separated  in  such  a  manner  as  to  stop  up  the  nasal  orifices. 
There  is  a  hole  in  each  pad,  which  communicates  with  two 
short  bits  of  india-rubber  tubing  joining  into  a  single  tube.  I 
have  not  found  the  use  of  the  pads  as  convenient  or  efficient 
as  the  tip  inserted  into  the  nostril ;  but  as  some  practitioners 
have  thought  that  they  were  more  convenient  than  the  simple 
tube,  placed  in  the  nasal  meatus,  I  have  given  this  description 
of  Dr.  Allen's  apparatus.*  It  can  be  had  at  the  instrument- 
makers  in  New  York. 

*  On  Aural  Catarrh,  London/1871,  p.  79. 


BOUGIES.  311 


BOUGIES. 


Bougies,  for  the  purpose  of  dilating  the  Eustachian  tube, 
are  highly  spoken  of  by  some  writers.  Bonnafont  and  Kramer 
were  perhaps  the  first  to  use  them.  Guye*  of  Amsterdam,  also 
employed  them,  and  published  three  cases  of  emphysema  pro- 
duced by  their  use.  In  the  first  case  there  was  emphysema 
along  the  neck,  as  far  as  the  sternum.  In  three  days  it  passed 
away.  In  the  second  there  was  suddenly  considerable  dysp- 
noea. The  uvula  was  found  to  be  the  cause  of  the  trouble.  It 
was  very  much  distended  with  air.  An  incision  in  it  was  made 
at  once,  and  the  patient  again  breathed  quietly.  In  the  third 
case  a  fold  of  mucous  membrane  in  the  fauces  became  so  much 
swollen  immediately  after  the  use  of  the  bougie,  that  breath- 
ing became  difficult.  Here,  again,  snipping  the  fold  soon 
relieved  the  breathing. 

These  cases  probably  show  all  the  danger  there  is  in  using 
bougies.  They  are,  however,  somewhat  painful.  Among 
some  1500  private  patients,  I  have  recorded  but  one  case  in 
which,  after  a  fair  trial,  air  could  not  be  driven  into  the  Eu- 
stachian tube  by  means  of  the  catheter  or  Politzer's  method. 
In  cases  where  common  air  did  not  enter,  the  vapor  of  chloro- 
form did.  In  this  fact,  will  be  found  my  reason  for  not  resort- 
ing to  the  use  of  the  bougie  more  frequently.  Their  use  is 
chiefly  to  stimulate  the  mucous  membrane  lining  the  Eusta- 
chian tube,  and  thus  remove  the  swelling.  Complete  stricture 
of  the  tube  is  too  rare  an  occurrence  to  be  really  much  con- 
sidered as  an  indication  for  the  use  of  the  bougies.  I  find  in 
injections  of  vapors  or  fluids  the.  stimulant  thus  sought  with- 
out any  of  the  unpleasant  features  of  the  bougie  treatment, 
such  as  the  production  of  emphysema,  breaking  of  the  bougie 
in  the  tube  and  severe  pain.  Dr.  Noyes  reports  a  case  f  in 
which  a  fine  whalebone  olive-tipped  bougie  passed  into  both 
Eustachian  tubes  through  the  catheter,  produced  suppurative 
inflammation  of  the  middle  ear. 

In  the   discussion  which  ensued  on  this  case,   Dr.  "Weir 

*  Arcliiv  fur  Ohrenheilkunde,  Bd.  II.,  p.  6. 

f  Transactions  of  the  American  Otological  Society,  Third  Tear,  p.  55. 


312  BOUGIES — ELECTEICTTY. 

said  that  he  had  tested  the  merits  of  the  bougie  practice  for 
five  years,  and  felt  that  in  cases  where  obstruction  of  the 
Eustachian  tube  did  not  yield  readily  to  Politzer's  bag,  the 
pump,  or  the  catheter,  the  bougie  was  of  very  material  assist- 
ance. In  a  large  experience  he  had  met  with  two  accidents, 
purulent  inflammation  of  the  middle  ear,  and  temporary 
emphysema  of  the  eyelids,  face,  and  neck.  These  accidents 
occurred  from  neglect  of  certain  rules  which  he  now  carries 
out.  Dr.  Weir  uses  catgut  bougies  on  which  are  marked  the 
length  of  the  catheter,  the  distance  to  the  isthmus  or  narrow- 
est part  of  the  tube,  74  millimetres,  then  the  distance  from  the 
point  to  the  tympanic  cavity,  11  millimetres,  and  finally  the 
width  of  the  cavity,  13  millimetres.  The  bougies  ranged  from 
Nos.  2  to  5  of  the  French  Scale. 

Dr.  Weir's  directions  as  to  the  employment  of  the  bougies 
are  so  thorough  and  careful  that  I  transcribe  them. 

The  instrument  having  been  passed  through  an  ordinary 
Eustachian  catheter,  and  "  once  engaged  in  the  tube  is  pushed 
onward  as  far  as  the  isthmus,  allowed  to  rest  then  a  few  mo- 
ments and  then  withdrawn,  and  air  gently  blown  in  through  the 
catheter.  If  the  air  did  not  readily  enter  the  tympanic  cavity, 
all  forcible  attempts  to  force  it  were  carefully  abstained  from 
and  the  bougie  reintroduced,  either  then,  or  preferably  at 
another  sitting,  and  carried  only  to  a  very  short  distance,  say 
one  or  two  millimetres  farther  on,  and  the  experiment  resorted 
to,  to  ascertain  if  the  tube  were  open."  Dr.  Weir  has  found 
the  most  obstructions  in  the  first  portion  of  the  tube,  though 
in  several  instances  he  had  overcome  total  obstructions  at  the 
tympanic  orifice.  "  The  conical  French  bougies  should  be 
discarded  as  dangerous,  from  the  tapering  ends  being  too 
long  ;  but  the  catgut  bougies  might  be  made  slightly  conical 
by  rubbing  them  on  emery  paper." 

ELECTRICITY. 

This  is  an  agent  whose  real  value  has  been  much  under- 
estimated in  many  departments  of  medicine,  but  which  I  am 
inclined  to  believe  has  been  overrated  in  the  treatment  of 
aural  disease.     The  effects  of  electricity  on  the  acoustic  nerve 


DEATH  AFTER  USE  OP  THE  CATHETER.  313 

will  be  fully  discussed  in  the  third  part  of  this  volume, 
while  it  is  only  necessary  to  say  at  this  point,  that  not  much 
is  to  be  expected  from  the  use  of  electricity  in  chronic  non- 
suppurative inflammation  of  the  middle  ear.  Drs.  Beard  and 
Rockwell  *  think  that  "  the  best  results  are  obtained  in  those 
cases  passing  from  the  sub-acute  to  the  chronic  stage,  and  that 
then  they  are  brought  about  by  the  mechanical  action  of  the 
Faradic  current,  on  the  adhesions  within  the  middle  ear." 
These  are  just  the  cases  that  are  amenable  to  treatment 
by  the  catheter,  Politzer's  method,  and  applications  to  the 
pharynx. 

Before  closing  the  subject  of  the  employment  of  the 
Eustachian  catheter  in  aural  disease,  an  allusion  should  at 
least  be  made  to  the  singular  dread  of  the  instrument,  now 
happily  dissipated,  which  obtained  in  the  minds  of  the  pro- 
fession in  England  and  the  United  States.  This  dread  seems 
to  have  depended  upon  two  cases  of  death  from  the  use  of  the 
catheter  which  occurred  in  the  practice  of  a  certain  Dr.  Turn- 
bull,  then  of  London,  but  who  occasionally  visited  America, 
for  the  purpose  of  treating  aural  disease,  until  his  death,  which 
occurred  a  short  time  since,  as  I  have  been  informed.  These 
famous  cases  were  reported  in  the  London  Lancet.  In  the 
same  journal,!  there  is  a  letter  from  a  correspondent  ac- 
cusing this  Dr.  Turnbull  of  advertising  in  the  "  Times  "  in  an 
unprofessional  manner — that  is,  by  stating  that  he  could  cure 
"  any  case  of  deafness,  not  arising  from  organic  disease,  by  the 
use  of  a  peculiar  remedy." 

In  order  that  the  length  and  breadth  of  this  matter  of  the 
death  of  patients  from  the  use  of  the  catheter,  may  be  fully 
presented  to  the  profession  and  not  continue  to  be  darkly 
hinted  at,  I  quote  from  the  Lancet  %  the  account  of  the 
inquest  upon  these  celebrated  cases. 

"  On  Monday  evening  an  investigation  took  place  at  the  Carpenters'  Arms, 
Hoxton,  before  Mr.  Baker,  relative  to  the  death  of  Mr.   Wrn.  Whitbread, 

*  A  Practical  Treatise  on  the  Medical  and  Surgical  Uses  of  Electricity, 
p.  566. 

f  Vol.  II.,  1839.  \  Vol.  II.,  p.  558. 


314  DEATH  AFTER  USE  OF  THE  CATHETER. 

aged  66,  which  was  supposed  to  have  been  occasioned  by  an  operation  lately- 
performed  on  him  by  Dr.  Turnbull  of  Russell  Square.  It  appeared  that  the 
deceased,  who  was  in  the  enjoyment  of  good  health  up  to  that  time,  had  an 
operation  performed  upon  him  on  Thursday  week  by  the  above  physician,  which 
consisted  in  injecting  air  through  the  nostrils  for  the  relief  of  excessive  deaf- 
ness, under  which  he  had  been  for  some  time  laboriug.  Almost  immediately 
after  he  was  attacked  with  a  violent  swelling  in  the  throat,  and  though  the 
utmost  attention  had  been  paid  to  him,  he  expired  on  Thursday  last." 

"  Mr.  Wickham,  a  medical  gentleman  in  the  neighborhood,  deposed,  that  on 
making  a  post-mortem  examination  of  the  body,  he  found  that  the  inflamma- 
tion in  the  throat  was  not  sufficient  to  have  occasioned  the  death  of  the  de- 
ceased ;  death  was  produced  by  extensive  inflammation  of  the  brain,  which,  in 
his  opinion,  was  occasioned  by  natural  causes,  and  that  neither  the  operation 
nor  the  inflammation  of  the  throat  had  anything  to  do  with  it." 

"  The  jury,  on  this  evidence,  returned  a  verdict  of  '  Natural  death  by  the 
visitation  of  God.' " 

"  On  Friday  morning,  at  eight  o'clock,  an  investigation,  which  occupied  the 
greater  portion  of  the  day,  was  entered  into  before  Mr.  Wakeley,  M.  P. ,  and  a 
highly  respectable  jury  of  tradesmen,  at  the  Plough  Tavern,  Museum  Street, 
to  prosecute  the  inquiry  into  the  circumstances  connected  with  the  death  of 
Joseph  Hall,  aged  18,  who  died  whilst  undergoing  an  operation  for  the  cure 
of  deafness,  at  the  house  of  Dr.  Turnbull,  Russell  Square,  on  the  morning  of 
Saturday  last.  The  circumstances  connected  with  the  case  had  created  an 
intense  interest,  and  during  the  proceedings  the  inquest  room  was  attended  by 
many  of  the  leading  members  of  the  medical  profession." 

"  George  Kimber  merely  stated  that  he  and  deceased  were  in  the  employ  of 
Mr.  Jackson,  ornamental  composition  maker,  of  Rathbone  place.  He  saw  him  last 
alive  on  Saturday  morning,  about  seven  o'clock,  at  which  time  he  was  getting 
ready  to  go  to  Dr.  Turnbull's  to  be  operated  upon  for  deafness,  to  which  he 
was  subject ;  he  was  in  all  other  respects  quite  well  and  healthy." 

"  Charles  Spadbron,  of  Gravesend,  deposed  that  he  saw  the  deceased  about 
ten  o'clock  on  Saturday  morning  at  Russell  Square.  He  appeared  in  good 
health.  There  were  other  patients  present  at  the  time.  Mr.  Lynn,  the  gen- 
tleman who  assists  Dr.  Turnbull,  was  pressed  to  operate.  The  deceased  filled 
the  instrument  himself,  and  discharged  the  air  by  turning  the  cock.  (The 
instrument  was  here  produced,  and  the  witness  showed  how  it  was  filled. 
The  bottom  of  the  cylinder  was  held  fast  between  the  feet  and  the  piston, 
worked  up  and  down  by  the  handle  until  the  pump  became  filled  with  air.) 
The  operation  was  repeated  four  times  on  deceased,  but  the  tube  through  which 
the  air  passed  was  removed  by  Mr.  Lynn  from  the  right  to  the  left  nostril. 
On  the  tube  being  taken  from  deceased's  nostril  the  fourth  time,  he  fell  back 
in  the  chair,  apparently  lifeless,  and  never  spoke  afterward." 

"  In  answer  to  the  coroner,  the  witness  stated  that  he  had  had  the  operation 
performed  on  himself  four  times  at  a  sitting  ;  it  produced  a  swimming  in  the 
head,  and  a  portion  of  the  air  appeared  to  escape  by  the  mouth,  and  the  rest 
down  the  throat." 

"  Mr.  James  Reid  of  Bloomsbury  Square,  surgeon,  deposed  to  having,  by  order 


CAUSES  OF  INJURIOUS  EFFECT  OF  CATHETER.  315 

of  the  coroner,  made  a  post-mortem  examination  of  the  body  in  presence  of 
Messrs.  Liston,  Quain,  Savage,  and  Lyon.  Mr.  Eeid  went  into  a  long  general 
anatomical  statement,  but  the  only  points  strictly  bearing  on  the  case  were  the 
following :  That  he  found  a  thin  layer  of  blood  on  the  left  side  of  the  mem- 
brane, and  globules  of  air  under  it,  and  in  the  small  veins  of  the  brain.  That 
the  left  tympanum,  or  internal  ear,  had  its  lining  membrane  swollen,  of  red 
appearance,  and  there  was  a  slight  effusion  of  blood  in  it.  From  the  known 
plethoric  habit  of  the  deceased,  and  from  tbe  fact  of  his  having  exerted  him- 
self at  filling  the  air-pump  before  he  was  operated  upon,  he  should  say  the 
cause  of  his  death  was  apoplexy." 

"  Mr.  Savage,  lecturer  on  anatomy  at  Westminster  Hospital,  was  next  exam- 
ined, and  differed  from  the  last  witness,  and  stated  that  there  was  extravasated 
•blood  on  both  sides  of  the  membrane,  and  that  the  tympanum  of  the  right  ear 
was  affected  as  well  as  the  left.  He  did  not  consider  that  deceased  died  of 
apoplexy,  but  that  the  injection  of  cold  air,  through  the  Eustachian  tubes,  was 
the  primary  cause  of  deceased's  death." 

"  Mr.  Liston,  surgeon  to  University  College  Hospital,  stated  that  he  was 
present  at  the  post-mortem  examination,  at  the  request  of  the  coroner,  and  the 
probability  was,  that  deceased  died  in  a  continued  fainting  fit.  He  could  not 
easily  disconnect  the  forcible  injection  of  cold  air  into  the  tympanum  from  the 
effect  that  followed  it.  In  the  region  of  the  tympanum  were  a  number  of  small 
nerves,  connected  with  the  most  important  one  in  the  body,  which,  receiving 
an  impression,  would  cause  spasms,  or  other  fatal  affections  of  the  heart. 
Nothing  precisely  satisfactory  could  be  come  to  on  account  of  the  decomposed 
state  of  the  body." 

"  The  coroner  complained  that  though  the  subject  of  the  inquiry  had  died 
on  Saturday  morning,  no  notice  of  his  death  had  been  sent  by  Dr.  Turnbull  or 
Mr.  Lyon  to  the  summoning  officer  of  the  district.  He  wished  those  gentlemen 
to  give  some  explanation  of  their  conduct." 

"  Dr.  Turnbull  and  Mr.  Lyon  severally  entered  into  an  explanation." 

"  The  coroner  then  addressed  the  jury  at  considerable  length.  And  in 
accordance  with  the  spirit  of  his  observations,  the  jury  returned  a  verdict  of 
'Accidental  death,'  with  a  caution  to  Dr.  Turnbull  never  again  to  intrust  the 
instrument  of  operation  in  unprofessional  hands." — {Times) 

There  are  numerous  explanations  for  these  cases  ;  but  the 
account  of  the  post-mortem  is  not  exact  enough  to  allow 
us  to  say  which  of  them  are  correct.  The  first  -Darned 
patient  may  have  died  from  the  emphysema  produced  by  a 
wounding  of  the  tissue  by  the  point  of  the  instrument.  An 
examination  of  the  tissues  of  the  throat,  immediately  after  the 
accident,  would  have  determined  this  point ;  but  there  is  no 
account  of  such  an  examination  having  been  made.  The 
experiments  of  Voltolini*  show  that  all  traces  of  an  emphy- 

*  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  VII.,  No.  1. 


316  DURATION  OF  TREATMENT. 

senia  would  pass  off  within  ten  hours  after  death,  so  that  the 
post-mortem  examination  would  give  no  information  on  this 
point. 

The  surgeon  who  determined  that  death  was  produced  by 
inflammation  of  the  brain,  unfortunately  gives  no  account  of 
the  evidences  which  led  to  the  formation  of  this  opinion.  The 
second  patient  may  have  died  in  a  fainting  fit,  or  from  em- 
physema. 

The  air-pump,  is  now  scarcely  used  in  the  profession  as  a 
means  of  injecting  air  into  the  Eustachian  tubes,  because  the 
air-bag  is  quite  as  efficacious,  and  because  it  is  a  much  sim- 
pler apparatus.  The  management  of  an  air-press  should  cer- 
tainly never  be  left  to  the  patient. 

Voltolini,  in  the  experiments  to  which  allusion  has  been 
made,  killed  a  rabbit  in  a  few  minutes  by  wounding  the  tissue 
of  the  pharynx,  by  a  wire  passed  through  a  catheter,  and  then 
blowing  forcibly  into  the  opening.  He  thus  produced  great 
emphysema  of  the  neck  and  chest.  Voltolini  believes  that  the 
cause  of  death  of  the  rabbit,  was  a  pressure  upon  the  larynx 
by  the  emphysematous  tissue,  and  not  the  pressure  upon  the 
lungs.  Turnbull's  patients  may  have  both  died  from  the  same 
cause ;  but  as  we  do  not  know  the  instrument  used,  or,  in  fact, 
any  of  the  details,  we  can  only  surmise  the  real  cause. 

I  need  hardly  say  that  the  Eustachian  catheter  has  never 
been  even  suspected  of  being  the  cause  of  death,  since  the  time 
of  these  cases,  although  it  is  in  daily  use  by  physicians  in  all 
parts  of  the  civilized  world. 

Before  passing  on  to  a  consideration  of  the  operative  treat- 
ment for  this  class  of  aural  affections,  a  word  or  two  should 
be  said  as  to  the  length  of  time  a  case  should  be  treated.  In- 
asmuch as  we  cannot  hope,  in  many  of  the  cases,  to  do  more 
than  arrest  the  progress  of  disease,  and  perhaps  improve  the 
condition,  since  we  cannot  dismiss  them  as  cured — that  is  to 
say,  with  the  hearing  perfectly  restored,  the  tinnitus  aurium 
gone — we  desire  to  know  how  long  we  shall  treat  the  ears 
locally.  The  general  hygienic  treatment,  such  as  the  frequent 
employment  of  baths,  of  a  gargle,  the  exercise  of  great  care 
to  keep  the  extremities  warm,  to  avoid  taking  cold,  and  so  on, 


DURATION  OF  TREATMENT.  317 

should  be  kept  up  during  a  patient's  life,  and  he  should  be 
told  at  the  first  consultation  that  he  has  a  life-long  warfare  to 
engage  in,  unless  he  desires  to  end  his  days  with  the  use  of  an 
ear-trumpet. 

But  we  cannot  keep  up  a  local  treatment  of  the  Eusta- 
chian tubes  and  pharynx  indefinitely.  Those  who  believe 
that  a  catarrhal  pharynx  and  nares  can  be  thoroughly  cured 
in  our  climate,  that  a  disposition  to  colds  in  the  head,  can 
be  effectively  subdued  by  the  use  of  the  spray  of  nitrate 
of  silver,  or  the  spray  of  any  other  agent  used  by  means  of 
the  most  perfect  apparatus,  will  continue  to  use  these  means 
of  local  treatment  until  the  end  is  accomplished.  But  those 
who  have  been  less  successful  in  such  attempts,  must  fix  some 
limit  to  the  time  of  treatment.  If  it  be  proposed  to  get  the 
confidence  of  a  patient  suffering  from  chronic  non-suppurative 
middle-ear  disease,  which  is  progressive  in  its  character,  it  is 
proper  to  tell  the  whole  truth  at  the  first  consultation  and  say 
that  we  have  no  hope  of  making  him  hear  very  well  again. 
It  is  only  a«  question  of  arresting  the  progress  of  the  disease, 
and  perhaps  of  increasing  the  hearing  power.  To  this  end, 
about  twice  a  year,  they  should  receive  a  course  of  local  treat- 
ment until  the  disease  has  ceased  to  progress,  for  a  period  of 
time  varying  from  three  to  eight  weeks,  while  the  general  treat- 
ment is  to  be  a  life-long  course.  The  only  reason  that  these 
limits  of  time  are  fixed  is,  that  I  have  seldom  seen  anything 
accomplished  in  less  than  the  shorter  time,  or  after  the  longer 
term  has  expired.  Very  many  patients  leave  us,  at  the  outset, 
never  to  return.  Some  of  them  cannot  leave  their  families  to 
stay  in  a  large  city  while  their  ears  are  being  treated.  This 
difficulty  is  being  rapidly  met.  In  every  considerable  town 
reputable  and  educated  men,  who  have  found  that  there  is 
something  more  in  aural  practice  than  in  syringing  out  the 
wax  and  then  dropping  in  glycerine  to  restore  it,  are  giving 
attention  to  otology,  and  the  laity  are  beginning  to  reap  the 
fruits  of  this  cultivation  of  a  hitherto  barren  field. 

There  is  another  class,  however,  whom  such  advice  never 
influences.  One  of  their  family,  has  been  a  victim  of  chronic 
aural  disease  for  a  period  varying  from  two  to  twenty  years, 
and  they  have  at  last,  at  the  request  of  the  family  physician, 


318  DURATION  OF  TREATMENT. 

screwed  themselves  up  to  the  courage  of  consulting  a  special- 
ist. They  come  in  town  for  a  day's  shopping,  and  call  upon 
the  doctor,  meanwhile  always  being  in  a  great  hurry,  and 
sending  word  to  the  consulting-room,  that  they  have  come 
fifty  miles  to  see  him.  When  such  advice  as  I  have  delineated 
is  given,  and  the  almost  bewildered  physician  sits  down  to  lay 
out  a  plan  of  treatment  and  correct  the  improper  habits  of  life 
that  have  induced  and  maintained  the  disease,  he  finds  that  he 
is  dealing  with  persons  who  expect  magic  ear-drops,  vibrators, 
or  some  mysterious  and  quickly-acting  agent  that  will  restore 
the  hearing  in  the  interim  of  rest  of  a  New  York  shopping 
excursion.  Of  course,  such  patients  figure  in  the  statistical 
tables  under  the  head  of  "seen  but  once,  result  unknown" 
although  in  the  mind's  eye  we  can  set  them  down  as  going 
on  slowly  but  surely  to  the  ear-trumpet,  and  banishment  from 
social  intercourse. 


CHAPTER    XIV. 

THE   TREATMENT   OF  CHRONIC  NON-SUPPURATIVE  INFLAM- 
MATION—Concluded. 


OPERATIONS  UPON  AND  THROUGH  THE  MEMBRANA  TYMPANI. 

Operations  upon  and  through  the  membrana  tympani,  have 
assumed  a  new  importance  within  the  past  few  years,  in  chronic, 
as  well  as  acute  aural  disease.  It  is  generally  believed  that 
still  more  will  be  accomplished  for  chronic  aural  inflammation 
by  such  procedures.  There  is,  therefore,  a  justification  for 
a  full  consideration  of  this  subject,  such  as  I  shall  endeavor  to 
give  in  this  chapter. 

The  reader  of  otological  literature  will  be  almost  appalled 
by  the  amount  of  material  on  this  subject.  It  begins  with 
Cheselden's  experiments  on  dogs,  and  ends  as  yet,  with 
Weber's  operation  upon  the  tensor-tympani  muscle.  From 
the  mass  of  authorities  I  have  collected  such  a  history  of  this 
subject  as  will,  perhaps,  enable  the  candid  professional  mind 
to  come  to  a  knowledge  of  the  true  value  of  these  different 
proceedings,  as  far  as  they  have  as  yet  been  developed. 

I  am  indebted  to  a  brochure  by  Dr.  Hermann  Schwartze, 
of  Halle,*  for  the  portion  of  this  historical  sketch  that  extends 
to  our  own  day,  although,  wherever  possible,  I  have  consulted 
the  original  authorities  and  verified,  and  in  some  instances 
amplified,  Schwartze's  quotations. 

1650. — Johannes  Biolanus,  of  Paris,  about  150  years  be- 
fore the  time  of  Sir  Astley  Cooper,  who  is  usually  supposed 
to  be  the  originator  of  the  operation  of  perforation  of  the 
membrana  tympani,  inquired  if  it  would  not  be  possible  to 

*  Studien  Beobachtungen  iiber  die  Kiintsliclie  Perforation  des  Trommel- 
fells,  Archiv  filr  Ohrenheilkunde,  Bd.  II.,  S.  24. 


320  PEEPOBATION  OF  MEMBBANA  TYMPANI. 

improve  the  hearing  of  the  deaf,  by  destroying  the  membrana 
tympani.  He  was  led  to  make  this  inquiry  from  the  fact  that 
he  knew  of  a  deaf  person,  whose  hearing  ivas  restored  by  an 
accidental  rupture  of  the  membrana  tympani,  by  means  of  an 
ear-spoon. 

It  is  well  to  remember  that,  until  very  recently,  there  were 
no  exact  measures  taken  to  estimate  the  amount  of  hearing, 
and  that,  consequently,  such  phrases  as  "  the  hearing  was  re- 
stored," "the  hearing  became  perfect,"  as  they  occur  in 
ancient  books,  only  mean  that  the  hearing  was  improved, 
sometimes  very  much,  sometimes  very  little. 

1722. — About  a  hundred  years  later,  T.  Cheselden,  sur- 
geon to  St.  Thomas's  Hospital,  London,  well  known  as  the 
inventor  of  the  operation  for  artificial  pupil,  actually  operated 
upon  dogs,  and  I  quote  from  his  work  on  anatomy*  the  de- 
scription of  his  cases.  Speaking  of  the  membrana  tympani, 
he  says  :  "  I  found  it  once  half  open  on  a  man  that  I  dissected, 
who  had  not  been  deaf,  and  I  have  seen  a  man  smoke  a  whole 
pipe  of  tobacco  out  through  his  ears,  which  must  go  from  the 
mouth,  through  the  Eustachian  tube,  and  through  the  tym- 
panum, yet  this  man  heard  perfectly  well.  These  cases  occa- 
sioned me  to  break  the  tympanum  in  both  ears  of  a  dog,  and 
it  did  not  destroy  his  hearing,  but  for  some  time  he  received 
strong  sounds  with  great  horror." 

Cheselden  then  goes  on  to  say  that  an  anatomist  named 
St.  Andre  assured  him  that  "  a  patient  of  his  had  the  tym- 
panum destroyed  by  an  ulcer,  and  the  auditory  bones  came 
out  without  destroying  the  hearing."  I  have  only  been  able 
to  obtain  the  second  edition  of  Cheselden's  works,  but 
Schwartze  quotes  from  the  seventh,  where  the  author  states 
that  he  obtained  permission  to  perform  this  operation,  that 
was  then  esteemed  such  a  formidable  one,  upon  a  prisoner.  If 
the  prisoner  survived  the  operation,  he  was  to  have  his  free- 
dom. Unfortunately  for  science  and  for  the  criminal,  the 
proposed  subject  became  ill,  so  that  the  operation  was  in- 
definitely postponed.  Sir  Astley  Cooper  t  says  that  such  an 
outcry  was  aroused  by  the  inhumanity  of  the  proposed  oper- 

*  The  Anatomy  of  the  Human  Body,  London,  1732,  p.  250. 
f  Philosophical  Transactions,  1800,  p.  152. 


PERFORATION  OF  MEMBRANA  TYMPANI.  321 

ation,  that  Cheselden  never  again  obtained  permission  to  per- 
form it. 

1748. — Dienert,  of  Paris,  in  a  dissertation,  recommended 
perforation  of  the  membrana  tympani  for  the  purpose  of 
evacuating  blood  or  pus  from  the  cavity  of  the  tympanum. 
Itard  says  that  Julius  Busson  proposed  the  operation  six 
years  before  this. 

1760. — The  first  man  who  actually  performed  the  operation 
as  a  means  of  benefiting  the  hearing,  was  a  person  named  Eli,* 
who  seems  to  have  been  a  charlatan. 

Portal  and  Sabatier,  two  Paris  surgeons,  who  lived  at 
the  same  time  as  Eli,  knew  nothing  of  his  operations.  Portal 
proposed  to  puncture  the  membrana  tympani,  in  the  cases 
where  it  was  greatly  thickened.  Sabatier,  on  the  other  hand, 
proposed  to  perform  the  operation  upon  a  relaxed  membrana 
tympani. 

1788. — "Wilde  quotes  a  passaget  from  Dr.  Peter  Degravers, 
of  Edinburgh,  who  lived  in  1788,  and  who  styled  himself  pro- 
fessor of  anatomy  and  physiology,  which  shows  that  he  had 
performed  the  operation.  Degravers  says :  "  I  incised  the 
membrana  tympani  of  the  right  ear  with  a  sharp,  long,  but 
small  lancet.  I  left  the  patient  in  that  state  for  some  time, 
and  afterward  observed  that  it  had  united.  I  incised  again  the 
membrana  tympani  of  the  right  ear,  but  crucially,  and,  on  remov- 
ing some  of  the  parts  of  the  membrane  incised,  I  discovered 
some  of  the  ossicula,  which  I  brought  out."  Schwartze  naively 
remarks,  "  There  is  no  account  of  the  results  in  this  case." 

1800. — In  the  beginning  of  this  century,  at  about  the  same 
time,  and  independently  of  each  other,  Dr.  Karl  Himly,  then 
of  Brunswick,  Germany,  and  Sir  Astley  Cooper,  proposed  the 
operation,  especially  in  closure  of  the  Eustachian  tube.  Himly 
had  demonstrated  to  his  students,  in  1797,  by  experiments 
upon  the  human  cadaver  and  living  dogs,  that  the  operation 

*  The  following  paragraph  is  quoted  by  Gairal,  Lincke's  Sammlung,  Bd. 
V.,  p.  109,  in  proof  of  Eli's  operation :  "  Est  Lutetiae  homo  quidam  Eli  dictus, 
qui  surditatem  curare  audet,  dummodo  malum  nona  paralysi  nervi  septimi 
paris  oriater,  en  vero  eius  njethodum  tympanum  exscindit  et  suppositum  im- 
mittit.    Feci  experimenta  quaedam,  quae  satis  bene  ipsi  cessarunt." 

\  Aural  Surgery  English  edition,  p.  15. 

21 


322  SIE  ASTLEY  COOPER'S  OPERATION. 

could  be  easily  and  safely  performed  ;  but  he  did  not  perform 
it  on  the  living  subject  until  1806.  He  reports  a  brilliant 
result  in  one  case  only,  in  a  person  suffering  from  syphilitic 
ulcers  of  the  pharynx,  who  had  been  deaf  for  years  from 
closure  of  the  Eustachian  tube. 

After  Sir  Everard  Home  had  published  his  paper  on  the 
functions  of  the  membrana  tympani,  a  paper  to  which  allusion 
has  already  been  made  in  this  volume,  Sir  Astley  Cooper 
published  a  careful  and  exact  account*  of  the  case  of  a  medi- 
cal student  at  St.  Thomas's  Hospital,  in  London,  who  had  lost 
his  membrana  tympani,  but  who,  nevertheless,  could  hear 
quite  well. 

The  student  was  twenty  years  of  age,  and  applied  to  Sir 
Astley  in  the  winter  of  1797.  He  was  attacked  at  ten  years 
of  age  with  suppuration  in  the  left  ear,  and  in  about  twelve 
months  after  with  the  same  disease  in  the  other  ear.  There 
was  a  profuse  discharge  for  weeks  from  both  ears,  and  in  the 
discharge  bones,  or  pieces  of  boues,  were  observable.  The 
patient  was  totally  deaf  for  three  months ;  the  hearing  then 
began  to  return,  and,  in  about  ten  months  from  the  last  attack, 
it  was  restored  to  the  state  in  which  it  was  when  he  consulted 
the  great  English  surgeon.  Sir  Astley  then  gives  an  account 
of  the  means  by  which  he  decided  that  the  drum-heads  were 
perforated.  The  patient  having  filled  his  mouth  with  air,  he 
closed  his  nostrils  and  contracted  his  cheeks  :  the  air  thus 
compressed  was  heard  to  rush  through  the  meatus  auditorius 
with  a  whistling  noise,  and  the  hair  hanging  from  the  temples 
became  agitated  by  the  current  of  air  which  issued  from  his 
ear.  "  To  determine  this  with  greater  precision,  I  called  for  a 
lighted  candle,  which  was  applied  in  turn  to  each  ear,  and  the 
flame  was  agitated  in  a  similar  manner."  The  examination  of 
the  case  was  continued  in  this  thorough  manner. 

The  gentleman,  when  in  company,  was  capable  of  hearing 
what  was  said  in  the  usual  tone  of  conversation,  and  he  could 
hear  with  the  ear  in  which  there  was  no  trace  of  a  membrana 
tympani,  better  than  with  the  one  in  which  there  was  merely 
a  circular  opening.    When  a  note  was  struck  upon  the  piano, 

*  Philosophical  Transactions,  1.  c. 


SIR  ASTLEY  COOPER'S  OPERATION.  323 

he  could  hear  it  but  two-thirds  of  the  distance  at  which  the 
examiner  could  hear  it. 

Although  this  case  was  accessible  to  the  profession  from 
the  year  1800,  it  is  surprising  to  find  the  belief  still  widely 
prevalent  among  the  laity  and  the  profession,  that  the  destruc- 
tion of  the  membrana  tympani  involves  almost  complete  loss 
of  hearing.  The  advance  in  the  simplicity  of  means  of  an 
accurate  diagnosis  in  aural  disease,  is  nowhere  more  distinctly 
seen  than  in  a  comparison  of  Cooper's  method  of  determining 
whether  the  membrana  tympani  be  intact  or  injured,  with  that 
of  the  surgeon  of  the  present  day,  who,  with  the  otoscope,  is 
able  to  state  just  what  the  condition  of  the  part  is,  with  no 
aid  from  the  patient,  and  in  a  very  brief  space  of  time. 

This  observation  led  the  way  to  the  operation  of  perforation 
of  the  membrana  tympani  *  for  the  relief  of  impaired  hearing. 
The  only  indication  that  the  great  English  surgeon  spoke  of 
was  closure  of  the  Eustachian  tub«,  which  he  believed  arose 
from  the  following  causes  : 

1.  A  common  cold  affecting  the  parts  contiguous  to  the 
orifices  of  the  tube,  and  thereby  preventing  the  free  passage 
of  air  into  the  tympanum. 

2.  Ulcers  in  the  throat,  from  the  scarlet  fever,  which  in 
healing  frequently  close  the  Eustachian  tubes. 

3.  A  venereal  ulcer  in  the  fauces,  by  the  cicatrix  it  pro- 
duces, may  cause  a  closure  of  the  tube. 

4.  An  extravasation  of  blood  in  the  cavity  of  the  tym- 
panum. 

The  scientific  character  of  Astley's  observations  is  nowhere 
better  shown  than  in  these  indications,  which  are  exact,  and 
in  consideration  of  the  state  of  knowledge  as  to  the  means  of 
opening  the  Eustachian  tube,  correct.  The  last-named  con- 
dition, however,  cannot  be  said  to  depend  upon  closure  of  the 
tube,  but  is  a  simple  case  of  hemorrhage  into  the  tympanic 
cavity,  which  no  affection  of  the  tube  would  be  likely  to  cause. 

Mr.  Cooper  reports  four  cases  : 

Case  I. — A  woman,  thirty-six  years  old,  who  had  been 
affected  for  eight  years.     The  deafness  arose  from  enlarge- 

*  Sir  Astley's  paper  descriptive  of  his  operations  was  read  June  21,  1801. 
See  Philosophical  Transactions  of  the  Royal  Society  of  London,  1801. 


324  SIE  ASTLEY  COOPEE's   OPEEATION. 

nient  of  the  tonsil  glands  ;  a  puncture  of  the  drum-head  was 
made,  and  while  she  stayed  in  the  consulting-room  for  one 
half-hour,  she  could  hear  ordinary  conversation. 

Case  II. — Ann  D.,  age  not  stated,  so  deaf  as  not  to  hear 
words  unless  spoken  close  to  the  ear.  She  had  been  affected 
for  six  weeks.  She  could  hear  a  watch  when  pressed  upon 
her  ear.  After  the  puncture  she  could  hear  the  watch  several 
feet. 

Case  III. — J.  E..,  aged  seventeen.  The  hearing  had  been 
impaired  since  birth.  There  was  an  imperfect  state  of  the 
fauces,  so  that  he  could  not  blow  his  nose.  The  Eustachian 
tubes  had  no  openings  into  his  throat.  Puncture  of  the  mem- 
brana  tympani  produced  such  a  confusion  that  he  nearly 
fainted,  but  in  two  minutes  he  recovered,  and,  two  months 
after,  his  hearing  continued  perfect. 

Case  IV. — A  person  was  sent  to  Mr.  Cooper,  who  had  re- 
ceived a  blow  upon  the  heaj,  which  had  occasioned  symptoms 
of  concussion  of  the  brain,  and  was  attended  with  a  discharge 
of  blood  from  each  ear.  He  recovered  from  all  the  effects  of 
the  blow  but  the  deafness.  Blood  was  found  in  the  meatus 
by  Mr.  Cooper.  After  clearing  this  away  and  perceiving  no 
benefit,  suspecting  that  a  quantity  of  blood  was  lodged  in  the 
tympanum,  in  a  few  days  he  punctured  the  membrana  tym- 
pani. Blood  mingled  with  the  wax  was  discharged  for  ten 
days,  during  which  time  the  hearing  was  gradually  restored. 

In  closing  his  paper,  Sir  Astley  states  that  little  pain  is 
felt  in  the  operation,  and  that  no  dangerous  consequences 
follow.*  The  Valsalvian  experiment  was  the  means  by  which 
he  determined  whether  the  Eustachian  passage  was  open  or 
not,  for  he  says  that,  when  the  experiment  succeeds,  the  tube 
is  open.  Besides  this,  the  patient  should  be  able  to  hear  a 
watch  placed  between  the  teeth  or  on  the  temporal  bones. 
Cooper  published  his  four  cases  of  good  results,  and,  accord- 
ing to  Schwartze  and  Frank,  he  was  soon  inundated  by  deaf 

*  Sir  William  Wilde  states  that,  within  a  few  months  of  his  death,  Sir 
Astley  exhibited  the  greatest  interest  in  this  subject,  and  left  his  consulting- 
room  full  of  patients  for  a  long  time,  to  send  for  a  man  in  Bond  Street,  upon 
whom  he  had  operated,  in  order  to  exhibit  him  to  Mr.  Wilde. —  Vide  Dublin 
Journal,  vol.  xxv.,  1844. 


PERFORATION   OF  THE  MEMBRANA   TYMPANI.  325 

persons  from  all  parts  of  Europe.  He  then  operated  on  fifty 
more  cases,  but  the  results  were  either  slight,  null,  or  they 
lasted  for  a  short  time  only.  Cooper  then  declined  to  see 
deaf  patients,  on  account  of  the  fact  that  he  was  doing  very 
little  good,  and  also  because  his  fame  as  a  surgeon  was  suffer- 
ing from  his  reputation  as  an  aurist.  After  the  lapse  of  more 
than  seventy  years,  the  dispassionate,  scientific  character  of 
Sir  Astley  Cooper's  writings  on  this  subject,  stands  in  striking 
contrast  to  the  charlatanism  of  some  of  those  who  followed 
him  in  this  operation. 

After  Cooper's  operations,  a  great  interest  was  excited 
in  France  on  this  subject,  and,  according  to  the  medical  jour- 
nals of  the  time,  quoted  by  Schwartze,  Biber  of  Bordeaux, 
Maunoir  of  Geneva,  and  others,  operated,  but  with  no  perma- 
nent results. 

In  Germany,  also,  the  same  interest  was  created.  Michae- 
lis,  a  professor  in  Marburg,  informs  his  friend  Hunold,  of  Ca- 
pel,  that  he  had  operated  on  one  case  successfully.  Hunold 
then  proceeded  to  puncture  every  membrana  tympani  to  which 
he  could  get  access.  Finally,  Hunold  records  that  he  has  had 
the  brilliant  result  of  curing  or  improving  seventy  cases  out 
of  a  hundred.  Subsequently,  it  was  shown  by  others,  that 
these  results  were  not  only  exaggerated,  but,  that  they  were 
not  even  at  all  in  accordance  with  truth.  Of  Michaelis's  sixty- 
three  cases,  in  forty-two  there  was  no  result  whatever;  while 
in  twenty-one,  or  one-third,  there  was  greater  or  less  improve- 
ment. But,  of  all  these,  in  only  one  was  there  a  permanent 
result  six  years  after ;  perhaps  the  benefit  was  permanent  in 
three  other  cases. 

Schwartze  says  that  after  Hunold's  marvellous  accounts  of 
his  successful  results  from  perforation  of  the  membrana  tym- 
pani, the  operation  became  the  fashion,  and  every  one,  who 
did  not  have  the  finest  hearing,  allowed  the  drum-heads  of  the 
ear  to  be  pierced.  Even  the  poor  deaf-mutes  had  their  drum- 
membranes  perforated.  Fashions  in  medicine  are  not  con- 
fined to  our  own  time. 

To  stem  this  tide  of  charlatanism,  Karl  Himly,  professor 
in  Gottingen,  wrote  a  commentary  upon  the  operation,  and 
showed  that  it  was  only  in  exceptional  cases  that  it  was  of  any 


326  PEEFOEATION  OF  THE   MEMBRANA  TYMPANI. 

value.  These  exceptional  cases  were  such  as  those  reported 
by  Cooper,  for  the  relief  of  which,  since  there  were  no  means 
of  opening  the  Eustachian  tube,  paracentesis  of  the  membrana 
tympani  was  a  beneficial  operation ;  but  the  profession  seem 
not  to  have  studied  Sir  Astley  Cooper's  cases,  but  it  was  merely 
known  that  he  perforated  the  membrana  tympani  with  benefit 
to  the  hearing.  Himly's  paper  excited  so  much  attention  that 
the  operation  was  not  heard  of  for  a  long  time. 

In  England,  as  we  have  seen,  Cooper  abandoned  the 
operation  and  otological  practice.  Stimulated  by  the  oppor- 
tunity for  entering  an  operative  field,  Saunders  opened  an 
aural  clinic  in  1804,  but  soon  closed  it  on  account  of  the  poor 
results  of  treatment.  He  speaks  of  one  case  of  perforation  in 
which  a  good  result  was  obtained.  After  him  came  Curtis, 
who  talks  of  the  operation  in  very  general  terms,  but  without 
furnishing  cases.  Buchanan  also  promises  to  describe  his 
cases,  but  he  never  did ;  and  Schwartze  thinks  that  Degravers, 
the  Edinburgh  professor,  from  whom  I  have  quoted,  and 
Stevenson,  are  not  to  be  relied  upon. 

In  France,  Itard,  Boyer,  and  Deleau  wrote  upon  this  sub- 
ject. Itard  was  wise  enough  to  perforate  a  drum-membrane 
of  a  deaf-mute  whose  tympanic  cavity  was  filled  with  masses 
of  tenacious  mucus,  and  he  succeeded  in  removing  them  after 
the  operation  by  syringing.  This  was  an  anticipation  of  Mr. 
James  Hinton's  operation.  In  one  hundred  and  seventy  other 
cases,  there  was  absolutely  no  result.  He  calls  attention  to 
the  fact  that  permanent  suppuration  may  occur  even  when  the 
operation  is  very  carefully  performed. 

1822. — Saissy,  of  Lyons,  in  his  work  on  the  ear,  speaks 
guardedly  of  the  operation,  and  of  only  one  case  where  the 
result  was  entirely  satisfactory.  Dr.  Nathan  R.  Smith,  of  Bal- 
timore, translated  Saissy' s  book,  and  invented  an  instrument 
for  perforation  of  the  drum-head,  which  he  described  in  the 
appendix  to  his  translation  ;  but  there  is  no  account  of  the 
success  of  the  operation  in  this  country. 

Schwartze  gives  very  little  credence  to  Deleau's  account 
of  his  successful  results.  He  claims  to  have  improved  eigh- 
teen out  of  twenty-five  deaf  persons  and  deaf-mutes,  by  the 
operation. 


PEKFOKATTON  OP  THE  MEMBBANA  TYMPANI.  327 

Hendriksz,  of  the  University  of  Groningen,  in  1828,  in  an 
inaugural  thesis  on  the  subject,  which  Schwartze  used  in  his 
historical  sketch,  states  that  in  the  institutions  for  the  deaf 
and  dumb,  in  Berlin,  Yienna,  and  Groningen,  this  operation 
was  frequently  performed.  In  Groningen,  eighty-one  deaf- 
mutes  were  operated  upon,  of  whom  seventeen  received  for 
the  moment  a  more  or  less  decided  improvement.  We  hear 
nothing  then  of  the  operation  for  twenty  years,  until  Hubert 
Yalleroux,  in  1843,  wrote  an  essay  upon  the  danger  attending 
it.     He  speaks  of  two  cases  of  death  from  it. 

Wilde,*  in  defence  of  the  operation,  when  performed  under 
proper  indications,  says  that  Dr.  Butcher,  of  Dublin,  reported 
two  cases  with  a  view  of  showing  the  ill-consequences  result- 
ing from  the  performance  of  the  operation,  and  relates  the 
cases  of  two  young  persons,  a  man  and  a  woman,  in  both  of 
whom  it  would  appear  that  death  ensued  from  puncturing  the 
membrane.  In  the  first  instance,  the  only  history  of  the  case 
is  that,  prior  to  this  period,  she  got  a  severe  cold,  with  a 
swelling  of  the  glands  of  the  neck.  No  account  is  given  of  the 
cause  or  origin  of  her  deafness,  the  condition  of  the  mem- 
brana  tympani,  why  the  operation  was  performed,  in  what 
manner,  by  whom,  or  with  what  instrument.  According  to 
Wilde,  all  that  we  know  is,  that  "  catheterism  of  the  Eusta- 
chian tube  was  performed,  and  said  to  fail;  hence  it  was 
agreed  that  the  membrane  of  the  tympanum  should  be  pierced, 
a  small  piece  being  drilled  out  of  the  membrane  of  the  right 
side."  No  exact  account  of  the  operation  and  no  names  of 
the  witnesses  are  given.  Inflammation  ensued,  and  four 
months  after  she  died,  when  the  petrous  bone  was  found 
roughened  and  softened,  and  the  membrana  tympani  entirely 
destroyed.  This  case,  certainly,  with  such  a  history,  can 
form  no  text  for  a  homily  against  paracentesis  of  the  drum- 
membrane. 

The  second  case  is  equally  indefinite.  Wilde  says  all  that 
is  known  of  the  case  is,  that  he  applied  to  a  surgeon  and  had 
his  tympanum  pierced,  "  but  why,  or  whether  with  a  gimlet 
or  a  punch,  a  trocar  or  a  probe,  we  are  not  informed.     At  first 

*  Text-Book,  English  edition,  p.  297. 


328  PERFORATION  OF  THE   MEMBRANA  TYMPANI. 

tlie  hearing  improved,  and  then  relapsed.  After  some  time 
head-symptoms  set  in,  and  the  man  died  in  six  weeks."  On 
the  post-mortem  examination,  the  brain  and  its  membranes 
were  found  in  an  inflamed  condition,  and  a  small  abscess  in 
the  anterior  lobe  of  the  brain,  on  the  same  side  upon  which 
the  puncture  was  made.  The  cause  of  the  deafness  in  this 
case  was  found  to  be  a  small  tumor,  about  the  size  of  a  bean, 
lying  on  the  acoustic  nerve. 

Paracentesis  of  the  membrana  tympani  was  certainly  not 
indicated  in  this  case,  and  the  two  together  form  no  more  of 
an  argument  against  the  operation,  than  the  indefinitely- 
reported  cases  of  death  from  the  use  of  the  Eustachian  cathe- 
ter do  against  the  use  of  that  instrument. 

The  treatises  on  diseases  of  the  ear,  of  Kramer,  Rau,  Bon- 
nafont,  Toynbee,  and  Von  Troltsch,  add  very  little  to  our 
knowledge  of  this  subject. 

It  has  thus  been  seen,  that  the  first  indication  which  was  set 
down  by  the  old  authors,  was  closure  of  the  Eustachian  tube. 
Since  the  scientific  use  of  catheters  and  bougies,  this  is  no 
longer  recognized  as  a  correct  indication  for  perforation  of  the 
drum-head.  In  the  very  rare  cases  in  which  there  is  an  imper- 
meable stricture  from  cicatrization,  it  would  be,  however,  a 
proper  operation. 

Thickening  of  the  membrana  tympani  was  another  promi- 
nent indication  of  the  old  authors — not  of  Cooper,  however. 
We  now  know  that  a  thickening  of  this  membrane  that  is  con- 
fined to  the  outer  layers,  may  be  removed  by  appropriate  local 
applications,  while  one  that  has  extended  to  the  fibrous,  or 
mucous  layer,  or  both,  is  nearly  always  accompanied  by  thick- 
ening of  the  whole  lining  membrane  of  the  cavity  of  the  tym- 
panum, so  that  this  indication  may  also  be  dismissed. 

A  collection  of  blood,  pus,  or  mucus,  in  the  cavity  of  the 
tympanum,  is,  then,  the  only  indication  of  the  old  writers 
which  may  fairly  be  said  to  be  up  to  the  present  standard  of 
knowledge.  The  collections  are  readily  diagnosticated  in  all 
acute  and  sub-acute  cases,  and  still  remain  good  indications 
for  perforation  of  the  membrana  tympani. 

From  this  chaos  of  illy-defined  indications  and  imitative 
experiment,  there  came  out  one  fact  in  proper  form.     That 


SCHWARTZES  EEVIVAL  OF  THE  OPERATION.  329 

one  fact  was  this  :  That  it  was  pre-eminently  proper  to  perfo- 
rate the  membrana  tympani  in  order  to  remove  mucus,  blood  or 
pus,  which  could  not  find  an  exit  through  the  Eustachian  tube. 
Sir  Astley  Cooper's  favorable  cases  showed  this  fact.  Itard's 
deaf-mute  was  also  another  illustration  of  its  truth ;  but,  through- 
out all  the  history  of  these  cases,  we  do  not  find,  until  we  come 
down  to  Saunders,*  and  later  to  Hermann  Schwartze,  of  Halle, 
that  one  writer  had  been  able  to  select  this  single  grain  of  wheat 
from  the  chaff.  Schwartze  saw  what  had  been  shown  by  the 
cases  that  were  published,  and  in  his  first  article  f  revived  the 
operation  of  paracentesis,  but  chiefly  applied  it  to  acute  disease, 
where  these  accumulations  of  mucus,  blood,  or  pus,  are  likely 
to  occur.  The  operation  is  now  well  established  as  a  means 
of  treatment  in  acute  cases,  and  has  already  been  described  in 
the  chapter  on  acute  catarrh  of  the  middle  ear. 

Schwartze  has  lately  published  one  hundred  cases  in  which 
he  has  performed  a  paracentesis  of  the  membrana  tympani. 
Before  passing  on  to  review  the  methods  of  writers  who,  since 
Schwartze's  paper  was  published,  have  modified  the  simple 
operation  and  enlarged  its  field,  so  as  to  cause  it  to  play  a  great 
part,  as  they  claim,  in  curing  chronic  cases  of  catarrhal  and 
proliferous  inflammation,  I  will  venture  to  criticise  Schwartze's 
table  of  results.  Of  his  one  hundred  cases,  only  two  were  in 
persons  over  fifty  years  of  age,  and  only  seventeen  were  over 
twenty.  The  remaining  eighty-one  were  under  that  age,  and 
forty-sis  were  between  one  and  ten  years.  In  America,  our 
cases  of  chronic  non-suppurative  inflammation  occurring  in 
young  persons  are  usually  quite  tractable  without  paracentesis. 
We  are  chiefly  anxious  to  enlarge  our  therapeutic  means  for 
the  cases  of  persons  who  are  more  than  sixteen  years  of  age, 
and  especially  for  those  who  are  adults  in  middle  life.  Again, 
in  thirty-four  of  the  cases,  the  disease,  whatever  it  was,  had 
not  existed  for  a  year.  There  were  only  ten  cases  where  the 
aural  affection  had  lasted  between  five  and  ten  years,  and  in 
six  cases  only,  more  than  ten  years. J 

These  statements  show  that  we  have  not,  as  yet,  even  in 
repeated  paracentesis  of  the  membrana  tympani,  found  the 

*  See  Introductory  Chapter,  p.  40. 

f  Archiv  fur  Olirenheilkunde,  Bd.  II.,  p.  36.  %  Ibid.,  Bd.  VI.,  p  195, 


330  politzee's  eyelet. 

remedy  for  the  class  for  which  we  in  America  are  most  anx- 
ious— old  and  neglected  cases  of  chronic  proliferous  inflamma- 
tion. Schwartze's  contributions,  in  other  words,  principally 
affect  acute  and  sub-acute  disease.  The  line  should  have  been 
a  little  more  distinctly  drawn  between  the  cases  of  sub-acute 
and  chronic  inflammation,  for  which  paracentesis  was  per- 
formed. 

1845. — It  was  thought  by  many  that,  if  a  permanent  open- 
ing could  be  kept  in  a  drum-head,  the  great  desideratum  would 
be  attained.  Bougies  were  placed  in  an  opening  made  with  a 
small  trephine,  and,  when  it  was  found  that  this  excited  too 
much  reaction,  a  gold  tube,  three  lines  long,  and  having  a  lit- 
tle ridge  on  both  ends,  was  inserted,  with  a  view  of  keeping 
up  a  permanent  opening.*  This  was  years  before  Politzer 
introduced  his  eyelet.  In  1868,  Politzer  had  a  case  in  which 
he  placed  an  eyelet  in  a  cicatrix  which  he  had  incised. 
Although  of  service  in  this  case,  it  has  proved,  however,  to  be 
beneficial  only  in  very  exceptional  cases,  where,  perhaps, 
repeated  paracentesis  would  do  quite  as  well.  Several  cases 
of  accident  have  occurred  in  its  use.  I  saw  one  case  in 
which  the  opening  had  closed  and  left  the  foreign  body  in 
the  cavity  of  the  tympanum.  I  saw  the  case  but  once.  Dr. 
Noyest  reported  another  case,  where,  in  attempting  to  insert 
the  eyelet,  it  was  lodged,  not  in  the  membrana  tympani,  but 
in  the  cavity  of  the  tympanum.  Eighteen  days  after,  at  the 
patient's  solicitation,  he  was  placed  under  chloroform  and  the 
eyelet  removed  by  making  quite  an  opening  in  the  membrana 
tympani.  The  suppuration  from  this  opening  ceased,  and  the 
opening  closed  in  sixteen  days.  The  hearing  distance  was 
improved,  from  contact  with  the  meatus,  to  three  and  one-half 
inches  while  there  was  an  opening  in  the  membrane ;  when 
the  opening  closed,  the  hearing  went  back  to  the  first-named 
point.  This  accident  of  escape  of  the  eyelet  into  the  tym- 
panum is  thus  one  quite  likely  to  happen,  either  at  the  time 
the  membrane  is  pierced,  or  subsequently.  The  suppuration 
which  occurs  is  more  apt,  however,  to  force  the  membrane 
into  the  auditory  canal  than  into  the  meatus. 

*  Frank's  Practisclie  Anleitung,  Erlangen,  1845,  p.  310. 

f  Transactions  of  American  Otological  Society,  third  year,  p.  57. 


EXCISION  OF  THE  MALLEUS.  331 

The  published  experience  of  those  who  have  performed  this 
operation  do  not  commend  it  as  a  successful  procedure,  and  I 
believe  that  it  is  now  very  seldom  performed. 

1867. — Wreden,*  of  St.  Petersburg,  went  far  beyond  the 
propositions  to  make  an  opening  in  the  membrana  tympani, 
and  excised  a  portion  of  the  handle  of  the  malleus.  Inas- 
much as  the  chief  vascular  supply  of  the  membrana  tympani 
was  along  the  handle  of  the  malleus,  Wreden  believed,  and 
with  correctness,  that,  by  cutting  this  off,  there  would  be  less 
probability  that  the  cicatrix  would  form.  He  says  that,  when 
he  removed  two-thirds  of  the  membrana  tympani  and  the 
handle  of  the  malleus,  he  never  saw  the  opening  fully  close. 
This  operation  never  found  much  favor,  for  the  reason  that  it 
proved  to  be  dangerous  to  the  hearing  and  even  to  the  life  of 
the  patient.  It  often  excited  an  otitis  suppurativa  of  so  severe 
a  form,  as  to  destroy  the  remainder  of  the  hearing  power.  It 
may  be  doubted,  too,  judging  from  analogous  cases  occurring 
accidentally,  whether  even  such  an  opening  would  not  heal. 
The  regenerative  power  of  the  membrana  tympani  is  indeed 
marvellous.  We  need,  however,  spend  very  little  time  over 
this  operation,  for  it  has  been  practically  abandoned  by  the 
imitators  of  Wreden,  if  not  by  the  distinguished  author  him- 
self. 

Voltolini,t  following  the  suggestion  of  Erhard,  made  the 
incision  with  the  galvano-cautery,  in  the  hope  that  the  open- 
ing made  in  this  way  would  be  longer  in  closing.  He  made  an 
incision  through  the  centre  of  the  posterior  section  of  the 
membrane.  There  was  a  crackling  sound,  as  if  one  passed  a 
knife  through  a  tense  paper.  This  first  operation  was  on  a 
patient  who  had  been  deaf  for  three  years,  and  had  suffered 
from  fever,  after  which  he  became  blind  from  cataract  and 
deaf  from  unknown  causes,  or  at  least  unstated  ones.  Imme- 
diately after  the  deafness  appeared,  which  is  stated  to  have 
been  complete,  he  was  treated  by  the  Eustachian  catheter,  but 
without  effect. 

Yoltolini's  first  operation  did  not  result  in  much  if  any 
benefit  to  the  patient,  but  it  proved  that  an  opening  made  by 

*  Monatsschrift  fur  Ohrenlieilkunde,  Bd.  I. 
f  Ibid.,  Bd.  I.,  p.  39. 


332  MYKINGODECTOMY. 

the  galvano-caustic  apparatus  could  be  kept  open  longer,  than 
one  made  by  the  knife.  Voltolini  improved  the  hearing  of  a 
patient  in  whose  membrane  he  had  made  an  opening  with  the 
galvano-cautery  to  such  an  extent,  that  a  watch  which  was  not 
heard  before  the  operation,  except  when  laid  upon  the  auricle, 
was  heard  more  than  an  inch,  and  ordinary  conversation  so  well 
that  the  patient,  who  was  a  shop-keeper,  was  able  to  carry  on 
his  business.  The  tinnitus  aurium  and  sensations  of  pressure 
in  the  head  were  also  removed.  The  painlessness  of  this 
method  makes  it  one  to  be  imitated,  and  where  we  find  that 
the  hearing  is  improved,  as  long  as  the  opening  remains  in  the 
membrana  tympani,  it  would  be  well  to  use  the  galvano-cautery. 

1863. — Gruber's  operation,  which  he  calls  "  myringodec- 
tomy,"  consists  in  forming  a  flap  in  the  membrana  tympani  by 
means  of  a  knife  and  forceps.  The  flap  is  cut  off.  Voltolini 
shows  that  this  operation  is  both  difficult  and  dangerous.  It 
is  difficult,  on  account  of  the  surgeon  being  obliged  to  work 
with  two  instruments  in  a  narrow  canal.  That  it  is  dangerous, 
is  shown  by  the  histories  of  the  cases  which  Gruber  gives ; 
e.  g.,  one  patient  had  fever  from  the  9th  to  the  21st  of  Novem- 
ber ;  and  quite  severe  hemorrhage  during  and  after  the  opera- 
tion, so  that  the  auditory  canal  was  several  times  filled  with 
blood.  Voltolini  also  calls  attention  to  the  fact,  that  Gruber's 
method  is  but  a  modification  of  the  old  operations  with  perfo- 
rators ;  but  we  may  say,  that  all  these  operations  are  modi- 
fications of  old  ideas  and  suggestions.  In  one  of  Gruber's 
cases,  the  opening  still  existed  five  months  after  the  operation 
was  performed. 

1868. — F.  E.  Weber,  of  Berlin,*  recommended  the  division 
of  the  tensor  tympani  muscle,  and  the  "  abnormal  adhesions 
that  may  occur  in  the  region  of  this  muscle."  One  of  the 
chief  indications  is  the  relief  of  pressure  upon  the  labyrinth 
from  retraction  of  the  tensor  tympani.  This  muscle  has  its 
origin  from  the  cartilaginous  portion  of  the  Eustachian  tube, 
and  runs  along  the  edge  of  the  bony  canal,  and  is  inserted  by 
a  well-defined  tendon  on  the  inner  angle  and  inner  surface  of 
the  handle  of  the  malleus. 

*  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  II.,  p.  51. 


DIVISION   OP  TENSOE  TYMPANI.  333 

Weber  thus  advanced  far  beyond  the  idea  of  maintaining  a 
permanent  opening  in  the  membrane,  and  carried  into  effect 
an  old  idea  of  dividing  abnormal  adhesions  that  may  form 
between  the  ossicula.* 

Dr.  Weber  published  an  article  in  January,  1872,  in  which 
he  goes  very  fully  into  the  object,  effect,  and  manner  of  per- 
forming his  operation.  It  is  well  known  that  the  great  Vienna 
anatomist,  Hyrtl,  was  the  first  to  suggest  this  operation,  but 
Weber  was  the  first  to  perform  it.  At  the  time  of  the  publica- 
tion of  Weber's  last  article  he  had  operated  upon  about  fifty 
cases. 

There  were  two  conclusions  which  led  Weber  to  the  per- 
formance of  this  operation :  1st,  The  fact  that  had  been 
demonstrated  that  the  tensor  tympani  muscle  kept  not  only 
the  membrana  tympani  and  the  ossicula  with  their  ligaments, 
but  also  the  labyrinth,  by  means  of  the  stapes,  in  a  state  of 
tension,  and  that,  consequently,  an  increased  tension  or 
rigidity  of  the  muscle  prevented  the  proper  conduction  of 
sound  and  increased  the  pressure  upon  the  labyrinth.  2d,  He 
also  reasoned  that  this  increased  tension  would  of  itself  ex- 
cite and  maintain  catarrhal  inflammation  of  the  tympanic 
cavity,  especially  if  there  was  at  the  same  time  an  affection 
of  the  tube,  and  that  it  might  cause  a  hinderance  to  the  cir- 
culation in  the  labyrinth,  with  tinnitus  aurium,  etc.  In  short, 
Dr.  Weber  thought  it  possible  that  many  varieties  of  non- 
suppurative affections  of  the  middle  ear  might  depend  upon 
excessive  contraction  of  this  muscle. 

The  instrument  which  Dr.  Weber  uses  for  the  operation 
is  exactly  figured  in  the  accompanying  engraving.  A  short 
and  thin  hard  rubber  speculum  is  used  so  that  there  may  be 
as  much  room  as  possible  for  manipulation.  The  head  is 
fixed  by  a  head-holder,  to  which  an  otoscope  is  attached ;  the 
head  may,  however,  be  held  by  an  assistant. 

The  tenotomy  is  divided  into  four  stages 

1.  The  membrana  tympani  is  perforated  with  the  hook- 
shaped  extremity  of  the  tenotome,  about  1 — l|mm.  in  front 

*  L.  c,  Jalirgang  IV.,  p.  143. 


334 


DIVISION  OF  TENSOR  TYMPANI. 


Weber's  Knife  for  dividing  the  Tensor  TyMpani  Musck. 


of  the  handle  of  the  malleus,  somewhat  below  and  to  one  side 
of  the  short  process, 

2.  The  hook-shaped  knife  is  pushed  forward  into  the  cavity 


DIVISION  OP  TENSOR  TYMPANI.  335 

of  the  tympanum — the  handle  of  the  instrument  being  brought 
downwards  and  forwards — and  thus  it  is  made  to  grasp  the 
tendon.  (Just  how  the  operator  is  to  know  when  the  hook  is 
around  the  tendon,  I  am  unable  to  learn  from  Dr.  "Weber's 
description.  I  suppose,  however,  from  previous  familiarity 
with  the  operation  on  the  cadaver.) 

3.  While  the  hook  is  about  or  over  the  tendon,  the  opera- 
tor exerts  a  gentle,  drawing  pressure  upon  it,  by  turning  the 
handle  of  the  tenotome  towards  the  face  of  the  patient ;  the 
hook  is  then  turned  a  third  upon  its  axis,  by  means  of  the 
button  which  acts  upon  the  cog,  and  the  tendon  is  cut.  A 
distinct  crackling  sound  is  heard  at  the  moment  of  the  divi- 
sion of  the  tendon. 

4.  The  hook  is  then  brought  away  from  its  position  by 
reversing  the  action  of  the  button  which  acts  on  the  cog,  and 
the  instrument  is  withdrawn. 

Dr.  Weber  at  a  later  date  gives  the  results  of  his  operation 
in  nine  rather  ponderous  formulas,  but  they  may  be  summed 
up  in  the  statement  that  it  is  claimed  that  the  operation,  in 
most  cases  for  which  it  is  properly  performed,  diminishes 
tinnitus  aurium,  vertigo,  prevents  many  persons  from  be- 
coming absolutely  deaf,  and  that,  if  a  permanent  result  is 
desired,  fluid  must  afterward  be  regularly  forced  into  the 
cavity  of  the  tympanum,  by  means  of  a  Weber's  pharmaco- 
Iconiantron. 

Weber  has  reported  cases  which  confirm  his  view  of  the 
benefit  from  the  division  of  tensor  tympani.  It  will  be  seen, 
by  reading  these  cases,  that  he  follows  up  the  operation  by 
the  most  decided  treatment  of  the  middle  ear,  thus  placing 
this  operation  where,  I  believe,  all  perforations  of  the  mem- 
brana  tympani  should  be  placed,  as  one  of  the  means  of 
assisting  in  the  thorough  medication  of  the  middle  ear  by  in- 
jections of  fluid  and  air.  Although  there  is  usually  a  tempo- 
rary effect  from  the  letting  up  of  the  intra-auricular  pressure, 
it  cannot  be  compared  to  such  an  operation  as  iridectomy  for 
glaucoma,  when  the  use  of  the  knife  ends  the  treatment. 

Gruber,  in  a  lecture  recently  delivered,  advocates  the  divi- 
sion of  the  tensor  tympani  muscle,  on  account  of  the  fact  demon- 
strated by  Helmholz,  that  this  muscle  moves  the  whole  chain  of 


336  DIVISION  OP  TENSOR  TYMPANI. 

the  ossicula  auditus,  as  well  as  the  malleus,  inward,  a  fact  which 
causes  us  to  believe  that  the  intra-auricular  pressure  must  be 
increased  and  morbid  changes  caused  by  any  excessive  con- 
traction of  this  muscle.  Gruber  calls  attention  to  the  fact 
which  he  was  the  first  to  show,  as  he  claims,  that  the  muscle  is 
inserted  not  only  on  the  inner  angle,  but  also  on  the  anterior 
surface  of  the  handle  of  the  malleus,  and  he  also  alludes 
to  what  we  have  already  noticed  in  the  chapter  on  the  ana- 
tomy of  the  middle  ear,  that  the  tensor  tympani  is  intimately 
connected  or  united  to  the  tensor  palati  muscle.  This  seems 
to  indicate  that  the  frequent  affections  of  the  soft  palate 
must  have  some  abnormal  influence  upon  the  tensor  tympani. 
Gruber  considers  the  indications  for  a  division  of  the  tensor 
tympani  to  be  a  retraction  or  contraction — a  shortening  of 
this  muscle.  These  indications  may  be  known  by  studying 
the  changes  on  the  folds  or  pockets  of  the  membrana  tym- 
pani. 

"  If  the  membrane  is  drawn  very  much  inward,  and  the 
lower  end  of  the  malleus  goes  with  it,  while  the  upper  retains 
its  position,  and  thus  the  posterior  fold  becomes  more  prom- 
inent, we  have  an  indication  of  the  abnormal  sunken  position 
of  the  drum-head."  Gruber  admits  that  this  sinking  of  the 
drum-head  may  depend  upon  other  causes  than  the  retraction 
of  the  tensor  tympani ;  but  these  may  be  readily  distinguished. 
The  excessive  contraction  of  the  muscle  causes  the  handle  of 
the  malleus  to  appear  broader,  and  the  membrana  tympani  to 
look  as  if  twisted,  in  a  state  of  what  in  surgical  language  is 
called  torsion.  The  anterior  ligament  of  the  malleus,  which 
passes  from  the  spina  tympanica  to  the  neck  of  the  malleus, 
also  becomes  more  prominent,  in  retraction  of  the  tendon  of 
the  tensor  tympani.  The  final  mark  of  retraction  of  the  mus- 
cle, according  to  Gruber,  is  the  more  or  less  rapid  reposition 
of  the  membrane  in  its  former  position  after  the  air-douche 
has  been  employed.  It  is  certainly  very  easy  for  us  to  verify 
these  indications,  as  given  by  Gruber,  and  it  is  to  be  hoped 
that  the  operation  will  have  a  fair  trial  in  the  class  of  cases 

*  Seperat-abdruck  aua  der  Allgemeinen  Wiener  Medizinischen  Zeitung, 
Jan.,  1872. 


DIVISION  OF  TENSOR  TYMPANI. 


337 


of  non-suppurative  disease,  for  which  we  have  as  yet  done  so 
little. 

Gruber   advises  that  the   tendon  be  usually  divided  as 
Weber  recommends,  in  front  of  the  handle  of  the  malleus. 


Fig  70. 


Grafter's  Knife  for  dividing  the  Tensor  Tympani. 


The  accident  that  may  possibly  happen,  if  the  membrane  is 
opened  posteriorly  to  the  malleus,  according  to  Gruber,  is  a 
perforation  of  the  carotid  artery,  if  the  carotid  canal  be  incom- 
plete in  its  bony  wall ;  but  this  kind  of  an  accident  seems  to 
be  almost  impossible,  with  any  care  in  the  management  of  the 
22 


338  DIVISION  OF  TENSOR  TYMPANI. 

tenotome.  As  another  argument  for  the  anterior  incision,  it 
is  stated,  that  the  labyrinth  cannot  be  entered  if  the  opening 
be  made  in  front  of  the  malleus,  while  the  knife  might  possi- 
bly go  through  the  foramen  ovalis,  if  the  opening  be  made 
posteriorly.  Gruber  uses  a  much  simpler  instrument  than 
Weber's  for  the  division  of  the  tendon,  and  one  which,  in 
my  judgment,  is  much  more  practicable.  It  is  represented 
on  the  preceding  page,  and  consists  of  a  narrow,  needle-like 
knife,  fastened  in  a  handle  at  an  obtuse  angle.  The  knife  is 
three  inches  long,  and  has  a  blade  cutting  only  on  the  anterior 
edge.  This  cutting  edge  is  ground  to  a  point,  and  curved  to 
such  an  extent  that,  when  the  instrument  is  passed  one-half  a 
millimetre  in  front  of  the  malleus,  through  the  membrana 
tympani,  and  the  needle  stands  parallel  to  the  long  axis  of 
the  auditory  canal,  the  point  of  the  knife  reaches  only  a 
little  above  the  border  of  the  handle  of  the  malleus,  but  does 
not  pass  far  upon  the  posterior  segment  of  the  membrana 
tympani. 

The  pain  from  the  operation  of  division  of  the  tensor  tym- 
pani is  not  usually  very  great,  and  it  is  seldom  necessary  to 
etherize  a  patient  for  the  purpose  of  performing  it.  Gruber 
performs  the  operation  in  cases  of  what  he  terms  hypertrophic 
or  plastic  inflammation  of  the  middle  ear  (proliferous  inflam- 
mation), where  the  ordinary  treatment  has  failed  to  benefit 
the  case.  The  head  of  the  patient  is  held  by  an  assistant,  the 
drum-head  well  illuminated,  and  the  tenotome  is  passed  through 
the  anterior  segment  of  the  membrane,  and  by  turning  the 
outer  end  of  the  knife  towards  the  face  of  the  patient,  the  point 
is  pushed  around  the  handle  of  the  malleus  to  the  other  seg- 
ment of  the  drum-head.  The  incision  is  then  elongated  about 
three  millimetres,  while  the  knife  is  held  in  the  same  position, 
and  then  withdrawn.  There  is  considerable  resistance  in  the 
tissue  when  the  tendon  is  divided,  and  a  crackling  sound  is 
heard.  The  hemorrhage  from  the  operation  is  usually  very 
slight.  The  air-douche,  by  the  catheter  or  Politzer's  method, 
should  be  used  after  the  cutting  is  finished,  and  the  ear  closed 
lightly  with  cotton,  while  the  patient  should  be  kept  quietly  in 
the  house  and  avoid  taking  cold. 

Those  who  doubt  whether  it  is  possible  to  divide  Lhe  ten- 


INCISION  OF  POSTERIOR  FOLD.  339 

don  without  also  cutting  other  parts,  will  have  their  doubts 
removed  by  performing  the  operation  on  the  dead  body  accord- 
ing to  the  directions  of  Weber  or  Gruber,  and  then  makiag 
an  examination  of  the  parts. 

Dr.  Orne  Green  recommends  that  Gruber's  operation  be 
done  by  making  the  incision  posterior  to  the  handle  of  the 
malleus,  and  with  a  little  broader  knife.* 

The  results  of  the  division  of  the  tendon  are  as  yet  not 
remarkably  brilliant ;  but  I  think  this  is  due  to  the  fact,  that 
cases  are  taken  when  many  more  changes  than  retraction  of 
the  tendon  have  occurred,  and  when  the  condition  of  the  mid- 
dle ear  is  beyond  all  therapeutic  aid.  It  having  been  demon- 
strated that  the  operation  is  a  safe  one,  and  that  it  usually 
has  a  temporary  beneficial  effect,  especially  in  diminishing  the 
tinnitus  aurium,  and  that  it  sometimes  does  substantial  bene- 
fit, we  may,  I  think,  hope  more  from  it  in  the  future,  when  it 
will  be  undertaken  at  an  earlier  stage  of  disease  of  the  middle 
ear.  If  thus  performed,  and  followed  up  by  treatment  of  the 
middle  ear  through  the  Eustachian  tube,  I  think  we  may  hope 
for  substantial  results  from  it. 

1871. — Lucae,  of  Berlin,  divided  the  posterior  pocket  or 
fold  of  the  membrana  tympani,  in  what  he  terms  "  dry  catarrh 
of  the  middle  ear  "  (proliferous  inflammation),  where  there  is 
a  marked  sinking  inwards  of  the  handle  of  the  malleus,  and 
great  prominence  of  the  short  process,  and  when  the  Eusta- 
chian tube  is  permeable.f  Lucae  uses  a  bayonet-shaped 
needle,  and  the  incision  is  made  from  below  upwards,  in  order 
to  avoid  cutting  the  chorda  tympani.  If  this  nerve  be  divided, 
it  is  probably  not  a  serious  accident,  judging  from  cases 
of  injury  to  the  drum-head  in  which  the  chorda  tjmpani  has 
been  injured.  Of  109  cases  operated  upon  by  this  method, 
Lucae  claims  to  have  greatly  benefited  46,  and  to  have 
improved  39,  while  in  24  there  was  no  benefit  from  the 
operation. 

A  question  of  priority  has  arisen  between  Dr.  Lucae  and 

*  Dr.  Green  has  some  preparations  made  by  himself  in  Wedl's  laboratory 
in  Vienna,  in  which  the  fact  that  the  tendon  is  exactly  and  cleanly  divided 
in  his  operation  is  clearly  shown. 

•j-  Seperat-abdruck  aus  der  Berliner  Klinischen  Wochenschrift,  1872,  No.  4 


340  pkout's  operation. 

Professor  Politzer  in  regard  to  the  performance  of  this  opera- 
tion, but  the  author  will  not  venture  to  discuss  this  subject. 

Politzer  performs  the  same  operation,  in  order  to 
^  render  the  membrane  more  movable,  under  the  name 
of  the  incision  of  the  posterior  fold  of  the  membrana 
tympani.  The  incision  is  a  longitudinal  one,  at  right 
angles  to  the  long  axis  of  the  fold,  between  the  short 
process  of  the  malleus  and  the  peripheric  end  of  the 
fold* 

1870. — Voltolini  advised  the  use  of  a  probe,  which 
is  introduced  daily  in  an  opening  made  by  the  gal- 
vanic cautery,  for  some  weeks  after.  I  am  not  able  to 
say  whether  Voltolini  has  found  this  method  a  certain 
means  of  maintaining  an  opening,  but  I  am  inclined  to 
think  not,  from  the  fact  that  so  little  is  heard  from 
him  on  the  subject. 

Dr.  Prout,  of  Brooklyn,  divides  adhesions  between 
the  membrana  tympani  and  the  promontory  with  a 
very  small  iridectomy-knife,  having  a  long  handle. 
His  principle  of  operation  is,  to  divide  the  adhesions 
according  to  their  situation.  I  have  seen  him  perform 
the  operation  in  two  cases. 

In  the  first  case  t  the  membrana  tympani  was  very 
much  sunken,  and  an  adhesion  to  the  promontory  had 
occurred,  as  shown  by  an  opaque,  yellow,  immovable 
spot  on  the  corresponding  point  of  the  membrane.  In 
performing  the  operation,  Dr.  Prout  used  a  knife  such 
as  is  here  represented. 

"  The  blade  is  bent  on  the  flat  at  an  angle  of  forty- 
five  degrees  ;  it  is  triangular  in  shape,  about  one  and  a 
half  lines  long,  and  three-fourths  of  a  line  broad,  sharp 
at  the  point  and  cutting  at  both  edges.  The  shank  is 
three  inches  long,  of  which  the  inch  next  the  handle  is 
not  tempered,  that  it  may  be  bent  to  any  desired 
ProuVs    angle.      The   handle   is   eight-sided,   that  it  may  be 

*  Translation  of  Politzer's  Lecture,  by  Dr.  Burnett,  Philadelphia  Medical 
Times,  vol.  ii.,  No.  56. 

|  Myringectomy,  followed  by  a  decided  improvement  in  the  hearing  power, 
in  a  case  of  adhesion  between  the  membrana  tympani  and  the  promontory. 
Transactions  of  the  Medical  Society  of  the  State  of  New  York,  1872. 


peout's  operation.  341 

rotated  between  the  thumb  and  finger  in  using  it,  and  is  two 
inches  long." 

The  patient  was  33  years  of  age,  a  teacher  by  occupation, 
and  had  been  treated  by  Dr.  Prout  for  some  time  previous  to 
the  operation,  for  advancing  non-suppurative  inflammation  of 
the  middle  ear,  but  in  spite  of  the  use  of  the  catheter,  Polit- 
zer's  method,  and  of  the  posterior  nares  syringe,  the  patient 
continued  to  grow  steadily  worse  as  to  her  hearing,  and  the 
tinnitus  aurium  became  so  unbearable  as  almost  to  unfit  her 
for  her  daily  duties. 

On  October  3, 1871,  the  patient  was  placed  under  the  influ- 
ence of  ether,  and  Dr.  Prout  having  illuminated  the  ear  by 
means  of  the  otoscope  upon  a  forehead  band,  entered  the 
knife  in  front  of  the  adhesion,  and  cut  around  the  promontory, 
with  which  the  end  of  the  handle  of  the  malleus  was  in  con- 
tact. By  means  of  "  a  little  cutting,  picking,  and  teasing,  a 
free  opening  was  made  of  about  one  and  one-half  lines  in 
diameter."  An  attempt  was  made  to  remove  the  piece  of  mem- 
brane adherent  to  the  promontory ;  but  the  operator  was  not 
certain  that  he  succeeded.  As  soon  as  the  patient  recovered 
from  the  ether,  she  said  that  she  heard  better.  The  warm 
douche  was  used  to  quiet  the  pain,  which  was  not  severe,  how- 
ever. The  hearing  power  for  the  voice  was  much  improved 
by  the  operation.  The  patient  was  able  to  hear  reading  and 
conversation  at  thirty  feet  in  front  of  her,  while  before  she 
could  on  one  side  only,  and  then  at  ten  feet.  There  was  a 
slight  purulent  discharge  for  about  a  week  after  the  operation ; 
but  no  very  severe  pain.  One  year  after  the  operation  the 
opening  in  the  membrana  remained  of  the  original  size  ;  the 
cavity  of  the  tympanum  was  dry  ;  the  watch  was  heard  when 
pressed  upon  the  auricle — before  the  operation  it  was  not 
heard  at  all — ordinary  conversation  was  readily  heard  at  the 
distance  of  twenty  feet. 

Dr.  Prout  thus  succeeded  in  maintaining  what  may  fairly 
be  called  a  permanent  opening  in  the  drum-head,  and  in  giv- 
ing great  relief  to  the  patient.  His  operation  of  dividing 
adhesions,  wherever  they  may  occur,  is  one  on  the  same  prin- 
ciple as  that  of  cutting  out  a  piece  of  iris  in  cases  of  posterior 
synechia,  and  certainly  forms  a  basis  for  future  experience. 


342  hinton's  operation. 

The  notes  of  Dr.  Prout's  second  operation  have  not  yet  been 
published. 

1869. — Mr.  Hinton,*  of  London,  believes  that  mucus  dries 
up  and  becomes  dense  in  the  cavity  of  the  tympanum,  and 
thus  becomes  a  cause  of  "  confirmed  deafness."  He  therefore 
incises  the  membrana  tympani  in  order  to  remove  this  har- 
dened mucus. 

Mr.  Hinton's  operation  consists  of  an  incision  in  the  mem- 
brana tympani,  through  which  fluid  is  injected  into  the  cav- 
ity of  the  tympanum  and  Eustachian  tube.  The  incision  is 
made  with  a  lance-shaped  knife,  in  the  inferior  and  posterior 
quadrant  of  the  drum-head,  and  is  from  two  to  three  or  even 
more  lines  in  length.  The  syringing  is  done  with  some  force, 
in  order  to  drive  out  of  the  cavity,  into  the  Eustachian  tube 
and  pharynx,  dried  or  inspissated  mucus,  the  collection  of 
which,  in  many  cases,  according  to  both  pathological  and  clin- 
ical experience,  is  the  cause  of  the  impairment  of  hearing  and 
the  tinnitus.  I  have  seen  Mr.  Hinton  perform  this  operation, 
and  two  cases  upon  which  it  had  been  performed  some  time 
before.  In  both  these  cases  the  patients  were  confident  that 
there  was  an  improvement  in  the  hearing,  and  a  lessening 
of  the  disturbing  symptoms  for  some  months  after  the  oper- 
ation. 

The  process  of  washing  out  the  cavity  of  the  tympanum, 
upon  which  Mr.  Hinton  lays  great  stress,  is  done  by  means  of 
a  syringe  fitting  hermetically  into  the  external  meatus.  A 
solution  of  bicarbonate  of  soda  is  used.  The  syringing,  which 
I  did  on  one  occasion  at  Mr.  Hinton's  clinique  at  Guy's  Hos- 
pital, London,  immediately  after  Mr.  Hinton  had  performed 
the  operation,  sometimes  causes  vertigo,  which  passes  away 
in  a  few  moments. 

Mr.  Hinton  once  divided  the  chorda  tympani  nerve  in  per- 
forming the  operation  of  incision  of  the  membrane.  "  The 
patient  felt  a  sudden  shock  running  down  the  tongue,  the  cor- 
responding side  of  which  suffered  an  impairment  alike  of  gen- 
eral and  of  special  sensibility  in  its  whole  extent.  The  patient 
began  to  recover  in  two  or  three  days."     The  most  frequent  ill 

*  On  Mucous  Accumulations  within  the  Cavity  of  the  Tympanum,  from 
the  Guy's  Hospital  Reports,  1869. 


hinton's  opekation.  343 

effect  is  an  inflammation  of  the  external  auditory  canal ;  when 
this  is  apprehended  the  ear  should  be  syringed  through  the 
Eustachian  tube  instead  of  the  meatus. 

Mr.  Hinton  performs  his  operation  in  sub-acute  or  quite 
recent  cases  of  accumulation  of  mucus  in  the  cavity  of  the 
tympanum,  as  well  as  in  those  of  long  standing,  such  as 
have  formed  the  subject  of  discussion  in  the  preceding  chap- 
ters. I  confess  to  a  little  skepticism,  however,  as  to  the  fact 
of  inspissated  mucus  being  the  sole  cause  of  the  impairment  of 
hearing  in  many  of  the  chronic  cases.  The  post-mortem  ex- 
aminations of  ears,  whose  f auction  was  much  impaired  for  a 
long  time,  that  have  as  yet  been  made,  do  not  reveal  this  as 
the  only  lesion  in  many  cases  ;  yet  I  think  the  operation  is  a 
good  one,  for  it  affords  an  opportunity  of  medicating  the  tis- 
sues of  the  middle  ear. 

My  own  experience  in  perforations  of  the  membrana  tym- 
pani  has  been  chiefly  in  the  manner  of  Schwartze  and  Hinton  ; 
that  is  to  say,  I  have  made  simple  paracenteses  or  openings 
into  the  membrane,  and  followed  them  up  by  treatment  of  the 
diseased  membrane  of  the  middle  ear.  Paracentesis  seems  to 
me  a  perfectly  safe  operation  ;  it  is  comparatively  painless, 
and  is  certainly  an  adjuvant  in  the  treatment  of  chronic  non- 
suppurative inflammation.  My  results  are  not  as  good  as 
Prof.  Schwartze's,  perhaps  because  I  have  been  in  the  habit 
of  treating  many  of  the  cases  that  he  treats  by  paracentesis, 
by  simpler  means. 

It  should  be  added  to  what  has  been  said,  that  the  para- 
centesis that  is  performed  in  chronic  cases  should  be  a  larger 
one  than  the  puncture  made  in  a  bulging  membrane,  to  give 
exit  to  blood  or  pus. 

From  the  experience  which  I  have  had,  and  from  a  careful 
consideration  of  the  recorded  experience  of  others,  I  think  we 
may  conclude — 

I.  That  paracentesis,  or  incision  of  the  drum-membrane  in 
chronic  non -suppurative  inflammation,  is  by  no  means  a  dan- 
gerous or  painful  procedure. 

II.  That  its  chief  value  is  in  furnishing  a  means  of  treat- 
ing the  lining  of  the  middle  ear. 

III.  That  it  may  properly  be  performed  in  cases  of  chronic 


344  INDICATIONS  FOE  PERFORATION  OF  DRUM-HEAD. 

proliferous  inflammation,  that  are  still  advancing  in  spite  of 
local  treatment  through  the  Eustachian  tube. 

IV.  Division  of  the  tendon  of  the  tensor  tjmpani,  and 
division  of  the  adhesions  existing  between  the  membrana  tym- 
pani  and  the  walls  of  the  cavity  of  the  tympanum,  are  opera- 
tions that  deserve  a  trial,  in  cases  of  chronic  inflammation  of 
the  middle  ear,  with  symptoms  of  increased  auricular  press- 
ure, not  relieved  by  a  fair  use  of  the  ordinary  means. 

In  the  choice  of  an  instrument  for  a  simple  paracentesis,  it 
seems  to  me  too  much  has  been  said.  For  Weber's  opera- 
tion, Gruber's  knife  seems  to  me  the  best,  and  for  Prout's 
operation  peculiar  instruments  are  required,  which  will  vary 
according  to  the  situation  of  the  adhesions,  their  size,  and  so 
on ;  but  for  the  ordinary  paracentesis,  whether  we  require  a 
long  or  short  incision,  a  puncture  or  a  flap,  an  ordinary  cata- 
ract-needle will  do  very  well.  Those  who  prefer  an  angular 
instrument  will  find  Blake's  knife,  that  which  is  attached  to 
his  modification  of  Wilde's  polypus  snare,  (which  should  be 
lengthened  in  the  shank,  however,)  one  of  the  best.  The  use 
of  an  anaesthetic  is  not  at  all  necessary,  except  where  adhe- 
sions are  to  be  divided,  and  the  dissection  is  to  be  therefore 
prolonged.  Some  of  the  German  authors  find  the  membrana 
tympani  very  sensitive,  even  under  chloroform  ;  but  I  have  usu- 
ally found  it  so  easy  to  make  a  perforation  with  very  little  pain 
— pain  so  trifling  that  it  is  forgotten  in  a  moment — that  I  am 
at  a  loss  to  conceive  any  other  reason  why  the  membrane 
should  be  so  sensitive  in  their  cases,  than  the  fact,  well  known 
to  American  surgeons,  that  Continental  practitioners,  who 
invariably  use  chloroform  and  not  ether,  as  we  do  in  this 
country,  are  so  timid  in  using  an  anaesthetic,  that,  very  often 
they  do  not  place  their  patients  in  a  condition  that  we  would 
consider  one  of  anaesthesia.  The  patient's  head  should  have 
a  good  rest,  and  the  otoscope  be  used  on  a  forehead  band,  so 
that  both  hands  may  be  free.  In  ordinary  perforations  for 
the  purpose  of  washing  out  the  cavity,  the  posterior  and  infe- 
rior quadrant  is,  perhaps,  the  best  position  for  the  incision. 

Some  of  the  instruments  formerly  recommended  for  perforation  of  the 
membrana  tympani,  were  probably  never  actually  used — such  as  one  very 
like  a  cork-screw,  and  a  red-hot  trocar.     Cooper  employed  a  small  trochar  in  a 


EFFECTS  OF  CONDENSED  AIR.  345 

canula,  the  point  of  the  trochar  projecting  at  the  most,  one  and  a  half  lines. 
Since  the  rigid  canula  would  be  apt  to  hurt  the  mcmhrana  tympani,  upon 
which  it  was  pressed  before  the  trochar  was  pushed  forward,  Saissy  used  a 
canula  of  elastic  wood,  which  caused  no  pain.  Itard  punctured  the  membrane 
with  a  blunt  probe.  Richeraud  recommended  that  the  opening  be  maintained 
by  the  subsequent  use  of  the  pure  nitrate  of  silver,  in  solid  form;  but  I  have 
found  the  use  of  this  caustic,  one  of  the  most  effectual  means  of  closing  an 
opening  from  an  old  suppurative  process.* 


THE  EFFECTS  OF  CONDENSED  AIR  UPON  THE  HEARING  POWER. 

From  some  peculiar,  but  unexplainable  tendency  in  the 
human  mind,  to  believe  in  marvellous  cures  from  means  not 
usually  employed  by  those  who  make  the  practice  of  medicine 
their  duty  in  life,  we  occasionally  hear  of  persons  who  have 
had  their  hearing  restored  by  entering  and  remaining  in  cham- 
bers— such  as  the  caisson  used  in  bridge  building — where  the 
air  is  condensed,  or  from  a  stay  in  the  so-called  pneumatic 
cabinets.  The  exact  observations  of  Magnus,  A.  H.  Smith,  and 
Green  of  St.  Louis,  show  that  these  accounts  of  cure  of  chronic 
non -suppurative  inflammation  are  not  based  on  facts.  On  this 
subject,  Dr.  Smithf  says,  "  Three  cases  of  extreme  deafness 
came  under  my  notice  ;  two  of  them  in  laborers,  and  one  in  the 
person  of  a  gentleman  who  was  advised  by  a  physician  to  visit 
the  caisson  in  the  hope  that  he  might  receive  benefit  from  the 
action  of  the  compressed  air.  In  all  these  cases  the  hearing 
was  very  much  improved  while  in  the  caisson,  but  on  return- 
ing to  the  open  air,  the  former  degree  of  deafness  immediately 
reappeared."  I  saw  the  gentleman  to  whom  Dr.  Smith  refers, 
and  diagnosticated  his  case  as  one  of  chronic  proliferous 
inflammation  of  the  middle  ear. 

It  might  as  well  be  claimed  that  deafness  is  cured  by 
riding  in  a  railway  carriage,  because  the  hearing  is  tempo- 
rarily improved  while  the  patient  is  there,  as  to  assert  that 
a  cure  is  found  in  condensed  air  because  persons  who  enter 

*  The  most  complete  account  of  the  instruments  used  or  recommended 
for  perforation  of  the  membrana  tympani  by  various  authorities,  is  found  in 
Beck's  Krankheiten  des  Grehororganes.     Heidelberg  and  Leipzig,  1827,  p.  45. 

\  The  effects  of  high  atmospheric  pressure,  before  quoted  in  Chapter  X. 


346  EXHAUSTION   OF  AIE  FROM  DRUM-HEAD. 

an  air-chamber  when  the  atmosphere  is  condensed,  hear  better 
during  their  stay. 

The  only  conceivable  means  by  which  a  sunken  drum-head 
could  be  improved  in  position  and  conducting  power,  by  re- 
maining in  a  chamber  of  condensed  air,  would  be  the  rupture  of 
the  membrane  from  the  force  of  the  air,  or  the  opening  of  the 
iubes  by  the  patient's  efforts  to  overcome  the  pressure.  Cer- 
tainly these  ends  can  be  accomplished  in  a  simpler  and  safer 
way. 

Dr.  Smith  found,  however,  that  sounds,  such  as  the  ticking 
of  a  watch,  were  not  heard  more,  but  less  distinctly  in  the 
condensed  air  of  the  caisson  ;  a  fact  which  he  accounts  for  by 
supposing  that  the  great  pressure  on  all  parts  of  the  auditory 
apparatus  opposes  a  mechanical  obstacle  to  the  freedom  of 
vibration.  "  At  the  same  time  the  velocity  of  the  waves  of 
sound  is  greater,  and  hence  the  pitch  is  higher.  A  deep  bass 
voice  is  changed  to  a  treble,  and  the  prolonged,  heavy  sound 
of  a  blast  is  so  modified  as  to  resemble  the  sharp  report  of  a 
pistol." 

Magnus*  says  that  the  conduction  of  sound  is  better  in 
compressed  air,  and  that  we  can  hear  the  same  tones  better 
than  in  the  ordinary  atmosphere,  provided  that  the  membrana 
tympani  is  not  placed  in  an  abnormal  condition — that  is,  an 
over  pressure  allowed  upon  it. 


EXHAUSTION  OF  THE  AIR  FROM  THE  DRUM-HEAD. 

Politzer,  recommends  the  exhaustion  of  the  air  in  the  ex- 
ternal auditory  canal,  by  plugging  the  meatus  with  a  bit  of 
cloth,  saturated  with  fat,  as  a  means  of  drawing  out  a  sunken 
drum-head,  when  we  have  reason  to  believe  that  the  tensor 
tympani  is  retracted.  Experience  has  no,t  shown  this  to  be  a 
very  efficient  means  of  treatment. 

Siegle's  otoscope,  or  pneumatic  speculum,  which  has 
already  been  described,  as  a  means  of  diagnosticating  adhe- 
sions between  the  membrana  tympani  and  the  walls  of  the  tym- 

*  Archiv  fur  Olirenheilkunde,  Bd  I.,  p.  280. 


RESULTS  OF  TREATMENT.  347 

panic  cavity,  has  lately  been  much  used  by  Dr.  H.  Pinkney,* 
assistant-surgeon  to  the  New  York  Eye  and  Ear  Infirmary, 
as  a  means  of  breaking  up  adhesions  in  the  tympanic  cavity, 
and  of  improving  the  hearing.  Dr.  Pinkney  attaches  the 
syringe  of  a  stomach-pump  to  the  apparatus,  and  exhausts  the 
air  by  the  use  of  this  instrument.  The  membrane  should  be 
carefully  watched  during  the  process,  lest  too  extensive  ecchy- 
mosis  or  a  rupture  occur.  I  have  employed  the  apparatus  in 
cases  of  chronic  proliferous  inflammation,  at  Dr.  Pinkney's 
suggestion,. but  as  yet  with  no  very  decided  results.  I  have 
also  cupped  the  membrana  tympani,  and  auditory  canal,  by 
placing  a  cup  over  the  auricle,  and  exhausting  the  air  by 
means  of  a  syringe  ;  but  with  no  beneficial  result. 

EESULTS  OF  TREATMENT. 

I  began  this  subject  with  the  statement  that  the  greater 
part  of  the  reproach  that  had  been  cast  upon  the  therapeutics 
of  aural  disease,  in  justice  applied  only  to  the  non-suppura- 
tive  affections  of  the  middle  ear.  Excluding  the  diseases 
of  the  labyrinth,  which  are  happily  much  more  rare  than 
those  of  any  other  part  of  the  ear,  it  is  just  this  class  of  cases, 
that  have  now  been  considered — non-suppurative  inflamma- 
tion of  the  middle  ear — that  are  most  intractable.  But  when 
all  this  is  said,  before  the  unpleasant  statistics  of  results  are 
presented,  a  few  words  of  explanation  should  be  made.  These 
affections  are  pre-eminently  local  in  their  character  ;  that  is  to 
say,  a  person  with  this  variety  of  aural  disease  may  have  the 
best  general  treatment  the  world  affords,  and  be  under  the 
most  appropriate  hygienic  conditions ;  he  may  live  in  a  climate 
like  that  of  Nice,  Mentone,  Naples,  Aiken,  or  St.  Augustine, 
and  then  he  will  not  recover  from  his  aural  disease,  nay,  more, 
he  will  continue  to  grow  slowly  but  gradually  worse  if  his 
pharynx,  Eustachian  tubes,  and  middle  ear,  are  not  treated 
by  the  appropriate  appliances  and  remedies. 

Until  ten  years  ago  there  was  scarcely  a  medical  college  in 
the  land,  except  the  University  of  New  York,  where  Prof. 

*  Verbal  communication. 


348  EESULTS  OF  TREATMENT. 

Post  taught  otology  in  his  course  of  surgery,  where  diseases 
of  the  ear  were  even  lectured  upon  with  any  fulness  and  correct- 
ness. And  even  now,  attendance  upon  the  otological  course 
of  our  colleges  is  entirely  a  voluntary  matter  with  the  student. 
The  result  is,  that  the  large  mass  of  general  practitioners 
know  nothing  of  the  rational  treatment  of  aural  disease,  and  a 
person  who  cannot  afford  to  stay  in  a  large  city  or  town 
where  there  is  a  surgeon  who  practices  otology,  must  go  with- 
out treatment.  Thus  many,  very  many  promising  cases,  from 
which  good  results  might  be  obtained,  are  never  treated. 
They  are,  perhaps,  diagnosticated,  but,  inasmuch  as  the  vic- 
tims of  them  are  surrounded  by,  and  cannot  get  away  from, 
those  who  "never  meddle  with  the  ear,"  they  go  down  to 
their  fate. 

The  following  table  gives  the  results  of  the  treatment  of 
four  observers.  I  can  only  account  for  the  fact  that  my  per- 
centage of  cures  is  less  than  the  others,  from  the  supposition 
that  I  have  seen  a  proportionately  larger  number  of  neglected 
cases  than  falls  to  the  lot  of  other  practitioners.  It  will  be 
observed,  however,  that  my  cases  show  a  larger  percentage 
of  improvement  than  those  of  the  other  observers.  I  have 
been  very  careful  in  the  tables  of  results  of  treatment  that 
I  have  published,  to  make  the  standard  of  cure  very  high. 
Those  only  are  classified  as  "  cured,"  in  which  the  hearing 
was  restored  to  a  normal  condition  as  tested  by  the  watch,  the 
tuning-fork,  and  ordinary  conversation.  Judged  by  the  ordi- 
nary use  of  the  term  cured,  this  standard  is  too  high.  It  is 
higher,  for  example,  than  that  in  ophthalmic  practice,  where 
the  removal  of  a  cataractous  lens,  so  that  the  patient  gets 
sight  enough  to  read  coarse  print,  is  called  a  cure  of  the 
cataract,  although  the  vision  obtained  may  be  only  two-thirds 
of  that  enjoyed  by  a  person  who  has  never  had  cataract.  In 
the  same  manner  we  speak  of  curing  a  bone  affected  with 
necrosis,  by  removing  the  diseased  portion,  even  if  consider- 
able deformity  be  left.  If  a  patient  who  has  suffered  for 
months  or  years  from  a  morbid  process  in  the  cavity  of  the 
tympanum,  recovers  to  such  an  extent  that  the  hearing  power 
is  greatly  increased,  although  it  may  not  become  normal,  he 
would  be  said  to  be  cured,  under  a  standard  no  higher  than 


EESULTS   OF  TKEATMENT. 


349 


that  usually  adopted  in  medical  statistics,  but  I  have  preferred 
in  my  table  to  put  such  cases  under  the  head  of  "  improved." 

TABLE 

Showing  the  Besults  of  the  Treatment  of  Chronic  Nonsuppurative  Inflam- 
mation of  the  Middle  Ear. 


Eepobtek. 

No.  of 

Cases. 

Cubed. 

Impeoved. 

Unimpboved. 

Unknown 

*Spencer  (St.  Louis) . . 

tSchwartze  (Halle). . . 

$Gruber  (Vienna) 

Eoosa  (New  York) . . . 

56 

230 
187 
514 

6,  16i|  Per  ct. 
of  those  actu- 
ally treated. 

30,  20prct. 

38,  32  pr  ct. 

23,  11  pr  ct. 

18,  50  pr  ct. 

94,  60prct. 
61,  60  pr  ct. 
160,  62prct. 

10,  27  pr  ct. 

30,  20  pr  ct. 

9,    9  pr  ct. 

171,  48  pr  ct. 

20 

75 
84 
159 

*  Eeprint  from  St.  Louis  Medical  Journal. 

+  Archiv  fiir  Ohrenheilkunde,  Bd.  L-V-,  passim. 

%  Monatsscnrift  fiir  Ohrenheilkunde,  Bd.  I.-TV.,  passim. 


CHAPTER    XV. 

ACUTE  SUPPURATION  OF  THE  MIDDLE  EAR. 

Acute  suppuration  of  the  middle  ear  commonly  occurs  as 
a  direct  and 'recognized  consequence  of  an  acute  catarrh  of  the 
same  part.  A  catarrhal  process  is  unchecked,  and  passes  on 
to  a  suppurative  one.  In  some  cases,  however,  the  catarrhal 
inflammation  is  unobserved — we  cannot,  however,  say  that  it 
does  not  occur — and  the  first  intimation  of  any  morbid  action 
given  by  the  ear  is  a  discharge  of  pus  from  the  auditory  canal. 
I  have  seen  several  cases  where  the  patients  have  assured  me 
that  the  first  idea  that  they  had  of  trouble  in  the  ear,  was  the 
moistening  of  the  canal  from  the  flowing  out  of  the  pus.  An 
examination  of  the  ear  in  such  cases  has  always  revealed  a 
perforation  of  the  membrana  tympani.  We  probably  never  see 
a  discharge  of  pus  from  the  surface  of  the  auditory  canal,  with- 
out previous  intimation,  by  pain  or  swelling,  that  an  inflamma- 
tion of  the  part  had  occurred.  It  is  my  belief,  however,  that 
the  cases  of  sudden  and  painless  perforation  of  the  membrana 
tympani  are  nearly  always  preceded  by  some  premonitory 
symptoms,  such  as  pharyngitis,  feelings  of  fulness  in  the  ear, 
impairment  of  hearing,  etc.  ;  but  that  the  failure  to  notice 
them  is  usually  to  be  attributed  to  carelessness  in  observation, 
and  to  be  regarded  as  another  indication  of  the  common  indif- 
ference to  an  inflammation  of  the  ear,  that  is  not  positively 
painful. 

Then,  again,  there  are  cases  where  pain  is  felt  long  before 
the  pus  is  discharged,  but  where  it  is  mistakenly  referred  to 
some  other  part  of  the  body.  Neuralgia  of  the  head,  is  a 
diagnosis  often  incorrectly  made  for  the  first  stages  of  acute 
catarrh  of  the  middle  ear. 

It  is  not  to  be  denied,  however,  that  there  are  cases  of 


ACUTE  SUPPURATION  OF  THE  MIDDLE  EAE.        351 

acute  suppuration  of  the  middle  ear,  where  the  initial  symp- 
toms of  swelling  of  the  lining  membrane  of  the  Eustachian 
tube  and  cavity  of  the  tympanum  are  so  quickly  passed  over, 
in  a  few  hours,  or  even  minutes,  as  to  be  practically  unrecog- 
nizable. 

Such  a  course  of  the  disease  is  frequently  observed  in 
phthisis  pulmonalis,  where  a  membrana  tympani  will  some- 
times break  down  from  an  accumulation  of  mucus  behind  it, 
and  go  on  to  suppuration  without  a  trace  of  pain. 

The  usual  origin  of  acute  suppuration  is,  however,  a  violent 
one.  The  severe  pain  of  acute  catarrh  is  unrelieved,  pus  is 
formed  in  the  cavity  of  the  tympanum,  the  lining  of  the  mas- 
toid cells  is  very  much  distended,  the  outer  surface  of  the  pro- 
cess becomes  red,  tender,  and  painful,  the  head  throbs,  and  the 
whole  system  is  seriously  disturbed.  In  young  persons  delirium 
occurs,  and  in  all  subjects,  there  is  general  febrile  excitement, 
and  the  condition  of  the  patient  is  one  of  intense  suffering. 
There  is  probably  no  more  severe  pain  to  which  the  human  sys- 
tem is  liable,  than  that  due  to  the  distension  of  the  little  space 
called  the  cavity  of  the  tympanum  by  mucus,  serum,  or  pus. 

Symptoms. — The  symptoms,  then,  of  this  disease  are  usu- 
ally pain  in  the  ear  and  head,  constitutional  disturbance  in  the 
way  of  febrile  action,  with  impairment  of  hearing,  and  tinni- 
tus. The  membrana  tympani  also  exhibits  marked  changes 
in  appearance. 

But  the  pain  may  be  entirely  absent,  as  we  have  seen,  and 
yet  the  inflammatory  process,  because  it  is  sudden  in  its 
origin,  be  fairly  entitled  to  the  adjective  acute.  The  cases  of 
the  painless  form  of  acute  inflammation,  in  persons  suffering 
from  phthisis  pulmonalis  before  alluded  to,  are  not  as  amen- 
able to  treatment  as  the  more  acute  cases.  I  suppose  this  fact 
is  partly  to  be  attributed  to  the  failure  in  the  general  nutrition, 
and  also  to  the  contiguity  of  a  diseased  mucous  membrane, 
which  is  constantly  acting  as  an  exciting  cause  of  trouble  in 
the  pharynx  and  Eustachian  tube. 

The  membrana  tympani  has  usually  lost  its  naturally  trans- 
parent appearance  in  a  case  of  acute  suppuration.  It  has  a 
boggy,  sodden,  or  swelled  appearance,  and  has  none  of  its  nor- 


352  ACUTE  SUPPUKATION. 

mal  distinguishing  marks  in  the  way  of  light  spot  and  handle  of 
the  malleus.  Yet  this  is  not  always  the  case.  I  have  seen  cases 
where  the  transparency  of  the  drum  membrane  was  almost 
unimpaired,  and  the  accumulated  pus  and  mucus  which  were 
bulging  it  out,  could  be  seen  through  it.  In  one  case,  that  of 
a  young  lady,  I  found  pus  not  only  in  the  cavity  of  the  tym- 
panum, but  also  between  the  mucous  and  fibrous  layer  of  the 
drum-head.  The  pus  moved  when  the  head  was  moved. 
She  recovered,  with  perfect  hearing  power,  and  a  sound 
membrana  tympani,  without  an  artificial  or  spontaneous  per- 
foration of  the  drum-head.  The  treatment  resorted  to  was  the 
use  of  leeches,  a  gargle,  and  Politzer's  method.  There  was 
considerable  pain  at  the  outset,  but  not  the  intense  pain 
which  is  usually  one  of  the  characteristics  of  acute  suppura- 
tion. The  patient  visited  my  office  daily  during  the  whole 
course  of  the  disease,  which  occurred  in  the  mild  weather  of 
spring. 

It  is  possible  that  some  cases  of  so-called  abscesses  of  the 
membrana  tympani,  should  be  regarded  as  examples  of  limited 
suppuration  in  the  tympanic  cavity.  I  have  not  as  yet  seen  any 
cases,  where  it  seemed  to  me  that  an  abscess  was  confined  to 
the  layers  of  the  drum-head,  without  any  communication  with 
the  cavity  of  the  tympanum  or  the  external  auditory  canal.  It 
should  be  added,  that  the  osseous  portion  of  the  bony  canal  is 
often  found  to  be  very  much  iuflamed,  in  conjunction  with  the 
symptoms  in  the  membrana  tympani,  the  cavity  of  the  tympa- 
num, and  the  mastoid  cells.  I  may  be  pardoned  for  reminding 
the  student,  that  it  is  often  impossible  to  draw  the  line  between 
the  affections  of  the  three  parts  of  the  ear.  Their  anatomical 
connections  show  that  they  must  of  necessity  run  into  each 
other,  however  distinctly  they  may  be  separated  in  their  ori- 
gin. It  is  rather  a  predominance  than  an  exclusive  localiza- 
tion of  symptoms  in  a  part,  that  gives  rise  to  an  exact  classifi- 
cation of  disease.  For  example,  an  otitis  media,  in  a  young 
child,  may  very  readily  and  rapidly  pass  on  to  an  otitis  in- 
terna, or  inflammation  of  the  labyrinth,  and  give  us  much 
difficulty  in  deciding  which  was  the  original  affection. 

Causes. — The  causes  of  acute  suppuration  of  the  middle 


CAUSES  OF  ACUTE  SUPPURATION.  353 

ear  are  the  same  as  those  that  have  been  enumerated  in  the 
chapter  on  acute  catarrh.  The  chief  one  is,  exposure  to  cold 
— inflammation  of  the  naso-pharyngeal  mucous  membrane 
being  the  usual  starting  point. 

The  violent  use  of  the  posterior  nares  syringe  in  an  acute 
or  sub-acute  catarrh,  will  also  in  very  rare  cases  set  up  acute 
suppuration  in  the  tympanic  cavity  ;  at  least  I  have  seen 
it  do  so  in  one  case,  which  was  the  following :  A  physician, 
aged  27,  had  suffered  for  years  from  chronic  naso-pharyngeal 
catarrh.  During  the  winter  of  1872,  he  was  attacked  with 
acute  coryza  and  pharyngitis.  He  had  once  used  the  nasal 
douche  for  a  similar  attack,  and  it  caused  such  severe  symp- 
toms that  he  was  obliged  to  desist  from  it.  I  was  in  the 
habit  of  using  the  naso-pharyngeal  syringe  for  him  at  irreg- 
ular intervals,  in  order  to  relieve  the  chronic  naso-pharyn- 
gitis  from  which  he  suffered.  On  visiting  him  one  afternoon, 
when  he  was  suffering  from  the  acute  attack,  his  nostrils 
felt  so  full  of  secretion  that  he  requested  me  to  use  the  naso- 
pharyngeal syringe,  which  I  did,  injecting  a  lukewarm  solution 
of  chlorate  of  potash.  The  bulb  of  the  instrument  caused  some 
gagging  as  it  came  in  contact  with  the  swelled  wall  of  the 
pharynx.  In  an  hour  or  two  he  was  attacked  with  acute  aural 
catarrh  of  the  left  side,  which,  in  spite  of  the  most  energetic 
treatment  by  means  of  leeches,  went  on  to  suppuration  before 
morning.  Under  appropriate  treatment  the  patient  recovered, 
with  a  sound  drum-head,  and  with  the  hearing  power  as  great 
as  before  the  attack. 

The  fact  has  already  been  mentioned  that  sea-bathing 
sometimes  becomes  a  cause  of  acute  catarrh.  In  the  same 
manner,  want  of  caution  in  protecting  the  side  of  the  head 
from  the  force  of  the  waves,  or  the  canal  from  the  entrance  of 
water,  may  produce  acute  suppuration. 

Scarlet  fever,  measles,  diphtheria,  tonsilitis,  bronchitis, 
pneumonia,  and  whooping-cough,  play  an  important  part  in 
the  production  of  acute  aural  disease,  and  usually,  the  suppu- 
rative form  is  the  one  first  recognized,  although,  as  has  been 
said,  there  is  probably  almost  always  an  unobserved  stage  of 
the  milder  variety  of  inflammation. 

Injuries  of  the  side  of  the  head,  and  of  the  membrana  tym- 
23 


351  ACUTE  SUPPURATION — COURSE. 

pani,  are  causes  of  acute  suppuration  of  the  middle  ear  of  a 
very  severe  nature.  This  subject,  has,  however,  been  discussed 
in  the  chapter  on  Injuries  of  the  Membrana  Tympani. 

Course. — The  course  of  acute  suppuration  is  usually  violent 
until  perforation  of  the  drum  membrane  occurs  ;  when  it  opens 
— at  times  with  quite  a  loud  explosion — relief  to  the  severe  pain 
is  usually  experienced.  If  no  measures  are  taken  to  remove 
the  accumulated  pus,  and  to  check  its  formation,  the  impair- 
ment of  hearing  will  continue,  although  the  pain  and  tinnitus 
may  be  relieved,  and  we  shall  soon  have  a  case  of  chronic 
suppuration  of  the  middle  ear,  and  the  patient  be  liable  to  all 
the  fearful  consequences  of  this  disease.  In  rare  cases,  pus 
may  escape,  however,  into  the  Eustachian  tube,  and  the  case 
go  on  to  resolution  with  no  perforation  of  the  drum-head. 
This  is  more  apt  to  occur  in  children  than  in  adults. 

In  the  worst  event  of  all,  the  suppuration  may  extend  into 
the  brain  or  the  circulation.  It  may  pass  through  the  thin, 
and  sometimes  porous  lamella  of  bone  which  forms  the  roof  of 
the  cavity  of  the  tympanum,  or  it  may  go  beneath  into  the 
jugular  vein,  and  thus  produce  blood  poisoning  or  pysemia. 
It  may  also  extend  to  the  labyrinth. 

The  mastoid  process  is  of  course  always  more  or  less 
involved  in  acute  suppuration,  or  even  in  acute  catarrh.  Its 
cells  form,  as  the  anatomy  shows  us,  an  integral  part  of  the 
middle  ear.  Disease  of  the  mastoid  process  is  also  a  danger- 
ous complication ;  but  for  a  full  discussion  of  the  subject,  I 
beg  to  refer  the  reader  to  the  consequences  of  chronic  sup- 
puration. 

Under  appropriate  treatment,  however,  the  secretion  of 
pus  usually  soon  ceases,  the  membrane  closes  up,  the  hearing 
is  restored,  and  scarcely  a  trace  is  seen  either  in  the  anatom- 
ical structure  or  the  functions  of  the  organ,  of  the  disease 
which  has  raged  so  violently. 

With  a  want  of  logical  reasoning  that  is  remarkable,  some 
practitioners  invite  suppuration  of  the  drum-head,  in  every 
case  of  acute  catarrh,  or  "  pain  in  the  ear,"  and  then  declare, 
that  nothing  can  be  done  for  the  hearing  when  the  membrana 
tympani  is  once  perforated.     Our   aim  should  always  be  to 


ACUTE  SUPPUEATION — TEEATMENT.  355 

prevent  or  limit  suppuration  in  the  ear,  but  if  it  do  occur,  and 
even  if  a  large  portion  of  the  drum-head  be  swept  away,  we 
may  usually,  if  the  ossicula  be  left,  by  prompt,  energetic,  and 
patient  treatment,  restore  it,  and  with  it,  the  hearing  power. 

It  should  be  observed,  that  diffuse  inflammation  of  the  ex- 
ternal auditory  canal  is  often  a  troublesome  complication 
in  the  course  of  an  aeute  aural  suppuration  Avith  perforation. 
It  is  probably  caused  by  the  irritation  of  the  pus  in  the  audi- 
tory canal,  and  perhaps  in  some  cases  by  the  excessive  mani- 
pulation for  the  purpose  of  cleansing  the  ear.  Such  a  com- 
plication is  sometimes  embarrassing ;  for  it  may  prevent  us 
from  continuing  the  astringents  which  are  indicated  for  the 
relief  of  the  suppuration. 

Treatment. — If  the  case  be  seen  in  the  earlier  stages — that 
is,  when  the  pain  is  still  present,  and  the  membrana  tympani 
is  intact — two  or  more  leeches  should  be  at  once  applied,  and 
if  the  appearance  of  the  membrana  tympani  indicate  that  it  is 
about  to  rupture,  or  if  the  pain  be  not  quickly  subdued  by  the 
use  of  the  leeches,  a  paracentesis  of  the  membrana  tympani 
should  be  at  once  performed  in  the  most  bulging  portion  of 
the  membrane.  If  the  mastoid  be  red,  tender  and  swelled,  it 
should  be  at  once  incised  down  to  the  bone,  except  in  the  case 
of  young  children,  where  the  more  yielding  nature  of  the 
integument  and  the  periosteum  will  admit  of  some  delay.  If 
the  mastoid  process  be  simply  red  and  tender,  but  not  swelled, 
the  use  of  leeches  will  probably  subdue  the  inflammation 
without  an  incision. 

The  ear  should  be  douched  very  often,  say  every  half  hour, 
with  lukewarm  or  hot  water,  the  temperature  of  the  water  be- 
ing determined  by  the  patient's  feelings.  This  procedure  the 
patient  will  usually  find  very  grateful.  In  case  of  the  absence 
of  a  douche,  warm  water  may  be  dropped  into  the  ear  from  the 
sponge,  a  procedure  as  old  as  the  time  of  Hippocrates.  A 
douche  may  be  extemporized  by  the  syphon  arrangement,  of 
a  bit  of  rubber  tubing  in  any  kind  of  a  vessel  that  will  contain 
water.  At  the  same  time,  especially  if  the  weather  be  cold,  the 
patient  should  be  kept  in  his  room,  and  perhaps  in  bed,  while 
pedeluvia  and  diaphoretics  are  employed. 


356  ACUTE  SUPPUKATION — TREATMENT. 

If  the  membrana  tympani  have  raptured,  the  pus  should 
be  removed  at  least  twice  a  day,  by  careful  but  thorough 
syringing.  At  the  same  time,  Politzer's  method  of  inflating 
the  ear  should  be  practised.  This  latter  procedure  gives  no 
pain  when  carefully  done,  i.  e.,  when  the  bulb  is  not  too  vigor- 
ously pressed.  It  at  once  improves  the  hearing,  helps  to 
cleanse  the  ear,  and  prevents  the  formation  of  adhesions  in 
the  cavity  of  the  tympanum,  and  gives  the  patient  hope  and 
confidence. 

The  throat  should  be  kept  free  of  secretion  by  a  gargle. 
The  chlorate  of  potash  in  a  saturated  solution  is  the  one  I 
usually  use.  In  cases  of  scarlet  fever,  the  pharynx  will  require 
the  most  careful  and  energetic  treatment.  The  neck  should 
be  kept  warm  by  poultices,  and  the  pharynx  be  very  often 
cleansed  by  the  use  of  a  nebulizer,  chlorate  of  potash  in 
powder  placed  upon  the  tongue,  and  so  forth.  Dr.  Sexton, 
of  this  city,  has  found  great  relief  in  tonsilitis  from  the  use 
of  the  warm  douche  upon  the  pharynx,  by  means  of  David- 
son's syringe,  or  rubber  tubing  attached  to  a  water  faucet. 

Relapses  of  pain  should  be  combated  by  leeches,  warm 
water,  and  the  internal  administration  of  opium ;  but  opium 
has  very  little  power  in  subduing  the  pain  from  acute  aural 
suppuration  if  used  without  the  local  treatment.  The  admin- 
istration of  calomel  or  other  mercurials,  the  application  of 
blisters,  will  not  be  required.  The  former  kind  of  treatment 
is  useless,  while  the  latter  aggravates  the  suffering  of  the 
patient.  Blisters  are  only  applicable,  if  at  all,  to  chronic  aural 
disease. 

If  the  case  go  on  well,  a  physician  who  does  not  see  much 
of  this  form  of  disease,  will  be  astonished  at  the  rapidity  with 
which  the  suppuration  is  checked,  and  the  membrana  tympani 
restored.  The  impairment  of  hearing  will  be  the  last  symp- 
tom to  be  fully  relieved.  The  hearing  power  should  be  often 
accurately  tested  by  the  watch  and  tuning-fork  in  the  course 
of  the  disease,  in  order  that  if  possible  we  may  not  dismiss 
the  patient  until  the  cure  is  complete. 

The  astringent  that  I  usually  use  in  acute  suppuration  is 
sulphate  of  zinc,  which  is  poured  into  the  ear  once  or  twice 
a  day,  after  syringing.     The  solution  should  be  previously 


ACUTE  SUPPUEATION — TEEATMENT.  357 

warmed.  Should  the  suppuration  continue  unduly,  the  nitrate 
of  silver  may  be  applied  in  strong  solutions,  say  from  40  to  80 
grains  to  the  ounce.  This  solution  is  brushed  over  the  drum- 
head and  in  the  edges  of  the  perforation.  In  some  cases 
it  may  be  necessary  to  drop  the  solution  into  the  ear,  after- 
wards neutralizing  it  by  syringing  with  a  warm  solution  of  salt 
and  water.  Indeed,  it  should  be  said  once  for  all,  that  except 
in  very  rare  and  exceptional  cases,  cold  fluids  should  not  be 
dropped  into  the  ear. 

From  the  nature  of  things,  the  general  practitioner  will 
see  a  great  deal  of  this  form  of  disease — if  he  be  on  the  look- 
out for  it — since  it  occurs  so  often  in  the  course  of  the  ex- 
anthemata and  in  connection  with  diseases  of  the  respiratory 
organs.  It  will  be  seen  that  there  is  nothing  in  the  treatment 
of  this  affection  that  will  prevent  the  usual  Gare  of  the  general 
disease.  It  is  a  great  and  often  fatal  error  to  wait  the  subsi- 
dence of  the  general  symptoms  before  the  aural  ones  are 
alleviated.  They  are  quite  as  important  as  the  most  urgent 
constitutional  disturbances.  Indeed,  they  are  often  the  un- 
suspected cause  of  most  of  the  latter. 

It  only  remains  to  be  said  that  the  results  of  treatment  of 
this  disease  are  very  satisfactory.  Of  32  cases  reported  by 
myself,*  15  were  cured,  i.  e.,  the  membrana  tympani  was  healed 
and  the  hearing  powerfully  restored,  as  tested  by  the  watch  and 
conversation.  As  has  been  said  in  another  place,  the  old 
writers  on  diseases  of  the  ear  were  not  in  the  habit  of  apply- 
ing accurate  tests  as  to  the  restoration  of  hearing ;  so  that 
their  standard  of  cure  is  not  so  high  as  that  which  obtains 
among  writers  of  the  present  day.  Many  of  my  cases  of  aural 
disease,  that  have  been  reported  as  improved  or  much  im- 
proved, would  have  been  classed  under  the  head  of  cured,  by 
the  less  exact  standard  of  ancient  writers.  Where  one  ear 
only  is  affected,  we  are  apt  to  be  led  into  error  as  to  the 
amount  of  deafness,  unless  we  are  careful  to  exclude  the  sound 
ear  as  thoroughly  as  may  be  in  our  examination.  Nine  of  the 
cases  were  improved,  and  the  result  in  the  remainder  of  the 
cases,  eight  in  number,  is  unknown  to  me,   although  it  is 

*  New  York  Medical  Journal,  August,  1869.  Transactions  Medical  Society 
of  the  State  of  New  York,  1871. 


358  ACUTE  SUPPUEATION. 

highly  probable  that  many  of  them  fully  recovered,  as  they 
were  chiefly  cases  occurring  in  consultation  with  brother 
practitioners,  who  undertook  to  carry  on  the  case  in  the  man- 
ner agreed  upon,  and  who  undoubtedly  had  a  good  result. 

The  consequences  of  a  neglected  or  improperly  treated 
aural  catarrh  are,  that  it  runs  into  a  case  of  acute  suppuration ; 
but  those  of  a  neglected  or  maltreated  acute  suppuration  are 
still  more  grave,  involving  as  they  do  all  the  perils  of  long- 
continued  suppuration  in  the  ear.  And  yet,  to  this  day,  there 
are  medical  men  of  very  great  general  intelligence,  who  think 
lightly  of  such  a  disease,  and  gravely  advise  patients  not  to 
"  meddle  "  with  it.  The  author  has  been  informed  by  a  dis- 
tinguished practitioner  in  this  city,  that  a  young  man  was 
once  sent  to  him  for  advice  by  an  eminent  physician,  after  he 
had  passed  through  a  severe  constitutional  disease  in  which 
suppuration  in  the  middle  ears  had  occurred,  for  whose  ears 
not  one  particle  of  rational  advice  had  been  given,  although 
both  membranse  tympani  had  been  destroyed,  the  ossicula 
were  gone,  and  the  mucous  membrane  of  the  tympanic  cavity 
was  granular.     Such  neglect  needs  no  commentary. 

The  course  of  acute  suppuration  occurring  in  the  midst  of  a 
severe  attack  of  scarlatina,  is  apt  to  be  very  violent.  The  symp- 
toms follow  one  another  with  the  rapidity  of  those  of  puru- 
lent ophthalmia.  He  who  wishes  to  preserve  the  integrity  of 
the  organ,  must  be  prompt  and  energetic  in  his  treatment,  or 
the  drum-head  and  the  ossicula  auditus  will  be  swept  away, 
and  a  profuse  and  fetid  discharge  of  pus  be  set  up  within 
forty-eight  or  fifty-six  hours. 

It  should  also  be  said  as  supplementary  to  this  subject, 
that  attacks  of  acute  aural  catarrh,  or  of  acute  suppuration  of 
the  middle  ear,  are  more  dangerous  in  persons  who  are 
affected  with  a  chronic  catarrh  of  the  middle  ear.  This  is 
explained  by  the  fact  that  the  drum  membrane  is  so  much 
thickened  in  such  cases  that  the  exit  of  the  pus  or  mucus  by 
its  spontaneous  perforation  is  much  more  difficult.  A  para- 
centesis will  be  much  more  likely  to  be  required  in  such  cases 
than  in  those  occurring  in  persons  with  drum  membranes  of 
normal  density  and  tension. 


ACUTE  SUPPUKATION — CASES.  359 


CASES. 


Case  I. — Acute  Suppuration  from  Scarlet  Fever— Loss  of  the  Malleus  of  each 
side — Reproduction  of  the  Membrana  Tympani — Great  improvement  in 
hearing  power. 

Harry ,  set.  9.     On  February  27, 1872,  I  was  called  by  Dr.  G.  S.  Winston, 

to  see  the  grandchild  of  a  gentleman  of  this  city,  in  regard  to  whose  case  I  had 
already  given  advice  by  mail  and  telegraph.  The  history  was  as  follows:  The 
boy  had  gone  back  to  his  school,  after  spending  the  Christmas  holidays  at  home, 
in  quite  as  good  health  as  usual ;  but  soon  after  arriving  he  was  attacked  with 
scarlet  fever,  which  rapidly  assumed  a  very  severe  type,  so  that  his  throat  was 
inflamed  and  the  cervical  glands  were  swelled,  and  the  lining  membrane  of  the 
middle  ears  was  in  a  state  of  very  acute  inflammation.  In  spite  of  prompt  and 
energetic  treatment,  by  the  physician  of  the  school,  suppuration  occurred  in  a 
few  hours.  After  the  aural  symptoms  occurred,  the  discharge  of  pus  became 
profuse,  so  that  the  ears  needed  cleansing  every  half  hour.  The  malleus  bone 
of  each  ear  escaped  in  the  pus,  and  I  have  them  in  my  possession.  When  the 
severest  aural  symptoms  had  subsided,  astringents  were  used  in  the  auditory 
canal,  and  the  Eustachian  tubes  treated  by  Politzer's  method. 

As  soon  as  the  little  patient's  general  condition  would  allow,  he  was 
returned  to  his  home,  and  in  a  deplorable  condition.  His  ears  were  discharg- 
ing thick,  offensive  pus,  in  such  quantities,  that  it  was  only  by  the  greatest 
diligence  in  cleansing  that  they  could  be  kept  clean  ;  the  naso-pharyngeal  space 
was  secreting  muco-purulent  material  in  great  masses.  The  hearing  power 
was  so  much  impaired  that  it  was  only  by  speaking  in  a  distinct  and  loud  tone, 
close  to  the  little  fellow's  ear,  that  he  could  be  made  to  understand  what  was 
said  to  him. 

The  family  and  friends  believed  that  he  would  become  the  inmate  of  a  deaf 
and  dumb  asylum.  Indeed,  a  gentleman — a  friend  of  the  family — who  had  a 
child  that,  having  lost  her  hearing  from  the  scarlet  fever,  had  learned  the 
method  of  speech  by  watching  the  lips,  came  to  see  Harry,  and  urged  that 
very  prompt  measures  should  be  taken  to  cause  him  to  learn  lip  reading,  inas- 
much as  he  felt  certain  that  he  would  never  hear  sufficiently  to  retain  his 
speech.  I  at  once  instructed  the  family  to  converse  regularly  with  the  little 
patient,  to  read  aloud  to  him,  and  to  urge  him  to  continue  to  talk,  while  the 
local  and  general  treatment  were  carried  on.  This  they  did  with  a  remarka- 
ble faithfulness ;  so  that  the  boy,  hearing  what  was  said  to  him,  never  acquired 
an  unnatural  tone  of  voice. 

On  examination  it  was  found  that  the  membrana  tympani  of  each  side  was 
gone,  and  that  the  cavity  of  the  tympanum  was  filled  up  with  granular  mucous 
membrane.  The  hearing  distance  for  the  watch  was  -4-8  on  each  side.  The 
voice  of  a  person  speaking  with  great  distinctness  was  heard  two  feet  from 
the  left  ear,  and  one  from  the  right.  Air  could  be  forced  through  both 
Eustachian  tubes.  The  patient's  general  condition  was  fair ;  but  he  was  suf- 
fering from  some  abdominal  effusion.  Dr.  T.  F.  Cock  was  called  "in  on  this 
account,  and  ordered  the  tincture  of  the  sesquichloride  of  iron.  The  weather 
being  cold,  the  boy  was  kept  in  the  house,  and  in  a  warm  room  ;  while  a  thor- 


360  ACUTE  SUPPUKATION — CASES. 

ough  local  treatment  was  entered  upon.  The  ears  were  syringed  by  some 
member  of  the  family  every  hour  during  the  day,  if  necessary  ;  while  I  visited 
him  at  first  twice,  and  subsequently  once  a  day,  and  cleansed  the  ears  with  the 
syringe  and  cotton-holder,  inflated  the  ears  by  Politzer's  method,  and  applied 
a  solution  of  nitrate  of  silver,  of  the  strength  of  forty  grains  to  the  ounce,  to 
the  cavity  of  the  tympanum.  The  family  applied  a  weak  solution  of  sulphate 
of  zinc  in  the  evening.  The  naso-pharyngeal  space  was  cleansed  by  the  use  of 
chlorate  of  potash.  A  weak  solution  of  Labarraque's  solution  of  chlorinated 
soda  was  used  in  the  water  employed  for  syringing  the  ear,  in  order  to  dimin- 
ish the  fetid  odor  of  the  pus.  Under  this  treatment  the  patient  steadily 
improved  until  the  discharge  of  pus  bad  entirely  ceased  from  the  left  ear,  and 
a  membrana  tympani  had  formed  at  the  bottom  of  the  canal,  with  a  small 
central  aperture,  and  in  the  right  there  was  also  a  membrane,  with  a  larger 
opening,  and  a  very  slight  muco-purulent  discharge.  On  May  11,  about  three 
months  and  a  half  from  his  return  to  the  city,  and  about  five  months  from  the 
breaking  out  of  the  scarlet  fever,  he  could  hear  the  voice,  with  his  face  away 
from  the  speaker,  for  a  distance  of  twenty  feet,  and  the  watch,  R.  E.,  -4%  ;  L.,  -£g. 
He  returned  to  school  in  good  general  health. 

January  9, 1873.— He  still  continues  at  school,  with  hearing  power  the  same 
as  last  noted.  The  membrana  tympani  of  left  ear  is  entirely  closed.  In  the 
right  there  is  still  a  small  opening,  and  occasionally  a  discharge  of  pus.  The 
ear  is  carefully  cleansed  at  school,  an  astringent  is  still  used,  and  Politzer's 
method  of  inflation  is  occasionally  practised. 

The  above  case  illustrates  what  can  be  done  for  one  of  the 
severest  cases  of  acute  suppuration  in  the  middle  ear,  result- 
ing from  the  pharyngeal  inflammation  of  scarlet  fever.  Hun- 
dreds of  such  cases  have  become  inmates  of  deaf  and  dumb 
asylums,  and  are  consequently  educated  in  a  necessarily  im- 
perfect manner.  This  boy,  although  under  some  obstacles,  is 
being  educated  exactly  as  are  his  fellows,  who  enjoy  good 
hearing  power.  I  think  the  right  membrana  tympani  will  be 
finally  closed,  and  that  he  will  then  be  free  from  the  dangers 
attending  the  chronic  suppurative  process. 

Case  II. — Acute  Suppuration  of  the  Middle  Ear,  occurring  in  a  Child,  in  con- 
nection with  the  Whooping-cough — Membranes  healed  in  about  a  Month. 

March  12,  1872. — Eugene ,  set.  1,  a  rather  delicate  child,  who  is  pass- 
ing through  the  whooping-cough.  A  few  days  ago  the  child  cried  very  much 
for  some  hours,  and  then  a  discharge  of  pus,  mingled  with  blood,  was  found 
from  each  auditory  canal.  The  spasms  of  coughing  are  very  severe.  I  was 
called  to  see  the  little  patient  a  few  days  after  the  discharge  of  pus  occurred, 
and  I  found* on  examination  that  both  membrana?  tympani  were  ruptured,  and 
that  considerable  pus  was  being  secreted  in  the  cavity  of  the  tympanum. 
There  was  also  some  naso-pharyngeal  catarrh. 


ACUTE  SUPPURATION— CASES.  361 

The  following  treatment  was  entered  upon  :  The  ears  were  syringed  three 
times  a  day,  with  lukewarm  water,  and  a  solution  of  sulphate  of  zinc,  gr.  ij. 
ad  3  j,  was  afterward  dropped  into  the  meatus,  and  kept  there  for  a  few  min- 
utes. I  saw  the  patient  three  times  a  week,  and  cleansed  the  ear  myself. 
On  April  15,  or  a  little  more  than  a  month  from  the  time  the  perforation 
occurred,  hoth  drum-heads  had  healed  and  the  discharge  had  ceased. 

Case  III. — Acute  Suppuration   in    the  Course  of  Chronic  Nasal   Catarrh — 
Paracentesis  of  the  Membrana  Tympani. 

George  S. ,  set.  34.  March  13,  1873. — Mr.  S.  has  had  "  catarrh"  for  two 
years,  for  which  he  has  been  in  the  habit  of  using  injections  through  the  nos- 
trils by  means  of  Davidson's  syringe.  For  the  past  few  hours  he  has  had  a 
pain  in  the  ears,  but  more  particularly  in  the  left,  and  he  cannot  hear  well. 

An  examination  shows  that  the  patient  has  a  severe  form  of  naso-pharyn- 
geal  inflammation,  attended  by  a  profuse  and  fetid  secretion.  The  hearing  dis- 
tance is,  R.  E.,  -/g- ;  L.  E.,  -4ag-.  The  right  membrana  tympani  is  sunken  and 
red.  The  left  membrane  is  very  convex ;  a  delicate  pink  tint  involves  the 
whole  surface,  and  there  is  no  trace  of  the  handle  of  the  malleus  nor  of  the 
light  spot. 

The  membrane  was  immediately  incised  in  the  upper  and  posterior  quad- 
rant, and  a  small  amount  of  pus  was  evacuated.  The  ears  were  inflated  by 
Politzer's  method,  and  the  auditory  canals  syringed  with  tepid  water.  A 
leech  was  applied  upon  the  tragus  of  the  right  ear.  A  profuse  suppuration 
occurred  in  the  left  ear  ;  but  it  was  soon  checked  by  the  use  of  a  solution,  gr. 
xl.  ad  %  j,  of  nitrate  of  silver  painted  over  the  drum-head,  aud  the  patient  disap- 
peared from  observation,  with  the  hearing  distance  ^|  on  each  side,  on  March 
22,  or  nine  days  from  the  date  of  the  first  visit.  I  afterwards  learned  that  he 
considered  himself  entirely  well. 

Case  IV. — Inflammation  of  Auditory  Canal  extending  to  the  Membrana  Tym- 
pani— Paracentesis — Cure. 

Mrs.  G.,  set.  about  35.  On  April  16,  1872, 1  was  sent  for,  by  request  of  Pro- 
fessor T.  G.  Thomas,  to  see  this  patient,  who  had  been  suffering  for  a  week  or 
two  from  occasional  attacks-  of  severe  pain  referred  to  the  depth  of  the  right 
ear.  These  attacks  had  been  alleviated  by  the  application  of  leeches,  but  the 
pain  continued  to  recur,  especially  at  night,  so  that  the  patient  was  unable  to 
sleep.  I  found  the  lady  suffering  very  much,  and  she  had  been  awake  with 
pain  all  night.  The  auditory  canal  was  found  to  be  swelled,  and  there  were 
two  points  of  suppuration  in  the  cartilaginous  part  of  the  meatus.  The  mem- 
brana tympani  was  red,  but  its  whole  surface  could  not  be  seen  on  account  of 
the  swelling  of  the  canal.  The  auditory  canal  was  scarified  at  two  points,  and 
the  use  of  the  douche  ordered  every  hour  ;  yg-  gr.  of  sulphate  morphia  was 
ordered  to  be  taken  every  hour,  until  the  pain  was  relieved.  In  the  evening 
the  pain  not  being  markedly  relieved,  two  leeches  were  ordered  to  be  applied 
to  the  ear — one  on  the  tragus,  the  other  at  the  glenoid  fossa.  This,  with  the 
continuation  of  the  morphia,  quieted  the  pain  very  much  ;  but,  on  the  19th,  I 
was  called  early  in  the  morning,  to  find  that  Mrs.  G.  had  had  a  recurrence  of 


362  ACUTE  SUPPURATION — CASES. 

the  pain,  and  that  she  was  suffering  very  much.  I  then  made  a  paracentesis 
of  the  drum  membrane,  although  the  swelling  of  the  canal  was  so  great  that 
I  could  only  judge  of  the  fact  of  my  instrument — a  cataract  needle — having 
passed  through  the  membrane,  by  the  depth  to  which  it  penetrated,  and  the 
yielding  sensation  communicated  to  the  fingers  as  the  needle  passed  through 
the  drum-head.  Immediate  and  great  relief  from  the  pain  was  experienced, 
and  the  patient,  under  the  continuation  of  the  douche,  daily  syringing,  the  use 
of  Politzer's  method  of  inflation,  on  May  11  she  had  fully  recovered  her 
hearing  power  with  a  moderate  amount  of  suppuration. 

I  am  not  able  to  decide  whether  this  case  was  primarily 
one  of  otitis  externa,  or  otitis  media.  I  am  inclined  to  think 
that  it  was  one  of  the  former,  and  that  the  inflammatory  pro- 
cess extended  to  the  membrana  tympani  from  without.  I 
suppose  that  the  membrane  was  unusually  thick,  perhaps 
from  a  previous  morbid  process,  and  that  this  accounts  for  its 
continuing  intact  for  a  longer  time  than  usual,  although  a 
membrana  tympani  that  is  invaded  by  disease  from  the  audi- 
tory canal,  will  withstand  an  inflammatory  action  without 
rupture  much  longer,  than  one  whose  mucous  layer  is  the  first 
affected. 

Case  V.— Acute  Suppurative  Otitis  Media  of  some  days  standing,  cured  by  one 
Application  of  a  forty-grain  solution  of  Nitrate  of  Silver. 

C.  C.  set.  1  year.  Feb.  16,  1873.— I  was  asked  to  see  this  little  patient  by 
Dr.  ft  ft  Lee.  There  had  been  an  acute  naso-pharyngeal  catarrh  for  some 
time,  and  for  a  few  days  there  had  been  a  purulent  discharge  from  the  left  ear. 
On  examination  the  drum  membrane  was  found  to  be  perforate,  and  there 
was  a  profuse  discharge  of  pus.  The  ear  was  kept  carefully  cleansed,  and  a 
warmed  solution  of  sulphate  of  zinc  poured  into  it ;  but  it  did  not  yield  in  a 
day  or  two,  when  a  solution  of  nitrate  of  silver,  of  forty  grains  to  the  ounce, 
was  brushed  over  the  canal  and  the  perforated  membrana  tympani.  At  my 
next  visit,  the  morning  after  this  application  was  made,  the  discharge  had 
completely  ceased,  and  the  membrana  tympani  had  healed. 

The  foregoing  cases  illustrate  the  ordinary  type  of  acute 
suppuration. occurring  in  subjects  of  different  ages.  The  prac- 
titioner who  has  not  seen  much  of  aural  disease,  may  be  at  a 
loss  when  called  to  a  case  of  acute  suppuration  of  the  ear,  to 
know  whether  its  seat  is  in  the  auditory  canal  or  the  middle  ear. 
The  parts  should  be  carefully  cleansed  of  pus  before  a  deci- 
sion is  made,  although  it  should  be  borne  in  mind,  as  was 
stated  in  the  chapter  on  acute  affections  of  the  canal,  that 


ACUTE   SUPPURATION.  363 

suppuration  in  the  middle  ear  is  much  more  frequent  than  the 
same  process  in  the  external  auditory  canal.  If  an  opening  in 
the  drum-head  cannot  be  detected  by  the  otoscope,  the  per- 
formance of  the  Valsalvian  experiment  by  the  patient,  or  the 
employment  of  Politzer's  method,  and  a  subsequent  inspection, 
will  determine  the  question.  If  the  membrane  be  perforate, 
the  air  will  be  heard  to  whistle  through  the  aperture,  and  an 
air-bubble,  made  by  the  pus  or  mucus,  will  be  found  at  the 
seat  of  the  aperture.  The  presence  of  an  air-bubble,  before 
the  parts  have  been  cleansed,  is  not,  as  Wilde  thought,  a 
pathognomonic  symptom  of  a  perforation,  for  I  have  seen  this 
bubble  when  the  membrane  was  intact,  but  fluid  was  lying 
upon  it. 


CHAPTER    XVI. 

CHRONIC  SUPPURATION  OF  THE  MIDDLE   EAR. 

The  chapters  in  which  acute  aural  catarrh  and  acute  suppu- 
ration have  been  considered,  have  prepared  us  for  the  descrip- 
tion of  the  disease  properly  known  as  chronic  suppuration  of 
the  middle  ear,  which  is  a  direct  consequence  of  these  affec- 
tions. It  was  formerly  almost  universally  known  and  de- 
scribed as  otorrhcea.  But  this  term,  simply  meaning  a  dis- 
charge from  the  ear,  and  being  one  that  does  not  in  any  proper 
way  define  the  seat  or  character  of  the  disease,  should,  I 
think,  be  banished  from  the  nomenclature  of  otology.  Chronic 
suppuration  of  the  middle  ear  is  the  affection  which,  among  the 
laity,  is  called  "  a  running  from  the  ear,"  and  which  has  been 
so  lightly  regarded  by  the  profession,  that  every  year  people 
die  from  its  direct  results,  and  under  the  observation  of  physi- 
cians, without  the  suspicion  that  the  disease  of  the  ear,  and  of 
the  ear  alone,  was  the  cause  of  their  death.  In  this  and  the 
following  chapter,  I  shall  attempt  to  set  forth,  in  a  plain  and 
simple  manner,  the  exact  nature  of  this  disease,  and  the  rea- 
sons why  it  should  never  be  neglected,  but  always  kept  under 
the  most  careful  observation  and  treatment. 

Chronic  suppuration  of  the  middle  ear  is  often  confounded 
with  that  rare  disease,  chronic  suppuration  of  the  external 
auditory  canal.  Very  many  times  patients  have  been  brought 
to  me  with  what  the  attending  physician  supposed  to  be 
merely  an  external  otitis,  but  which  proved  to  be  really  a  case 
of  suppuration  of  the  middle  ear,  with  perforation  of  the  mem- 
brana  tympani.  When  it  was  demonstrated  that  the  pus  had 
its  origin,  not  from  the  auditory  canal,  but  from  the  middle 
ear,   it   was  usually  an   easy  task  to   convince  the  person 


CHRONIC  SUPPURATION — FREQUENCY.  365 

affected  of  the  danger  of  a  neglect  of  the  disease.  I  feel  con- 
fident that  this  error  as  to  the  origin  of  the  affection  is  in 
many  cases  the  cause  of  its  neglect.  An  eczema,  or  a  so- 
called  seborrhcea,  or  even  a  suppurative  external  otitis,  may, 
perhaps,  when  occurring  with  young  children,  be  left  to  itself 
or  to  general  hygienic  attention  and  tonic  treatment  with  com- 
parative impunity  ;  but  the  best  of  such  care  will  not  avail 
to  stop  a  formation  of  pus  in  the  cavity  of  the  tympanum  or 
the  mastoid  cells,  unless  local  treatment  is  also  employed. 

We  might  almost  take  it  for  granted,  if  such  a  practice 
were  not  improper  in  a  physician  who  claims  to  observe  with 
exactness,  that  any  case  of  long-existing  suppuration  in,  or  dis- 
charge of  pus  from,  the  ear,  will  be  found  to  have  its  origin 
behind,  and  not  in  front  of,  the  membrana  tympani. 

I  have  already,  on  page  120  of  this  work,  alluded  to  this 
fact  of  the  comparative  infrequency  of  suppurative  affections 
of  the  outer  ear,  as  compared  with  those  of  the  middle  part  of 
the  organ ;  but  the  following  table  brings  it  out  more  strikingly 
than  the  mere  assertion  : 

TABLE 

Shouting  the  relative  frequency  of  Suppurative  Affections  of  the  External 

and  Middle  Ear. 

Number  of  Cases 
of  Inflammation  of  Suppura- 
Institution.                                         External  Auditory  tion  of  Mid- 
Canal,  excluding  die  Ear. 
Eczema. 

Brooklyn  Eye  and  Ear  Hospital,  1 870 93  246 

Massachusetts  Charitable  Eye  and  Ear  Infirmary,  ( 

-|072  •< including 36  cases 

(     of  myringitis. 

r  38  181 

Ophthalmic    and    Aural    Institute,  New  York,  J  including  11  cases 
1870-71 1  of  inflammation  of 

^  memb.  tympani. 

New  York  Eye  and  Ear  Infirmary,  1872 168  660 

Manhattan  Eye  and  Ear  Hospital,  1872 33  218 

502  1769 

All  the  cases  under  the  heading  Inflammation  of  the  Auditory  Canal,  were 
not  necessarily  suppurative ;  while  I  have  been  careful  to  place  only  the  sup- 
purative cases  in  the  middle  ear  column. 


366  CHEONIC  SUPPUKATION — SYMPTOMS. 

It  will  be  seen  by  the  table  that  the  cases  of  chronic  sup- 
puration preponderate  over  the  cases  of  chronic  external 
otitis,  in  a  proportion  exceeding  that  of  five  to  one.  I  am 
inclined  to  believe  that  the  proportion  is  actually  even  larger 
than  this,  and  that  in  some  cases  the  diagnosis  was  made  of 
external  otitis,  simply  because  at  the  outset  the  inflammation 
of  the  canal  was  so  great  as  not  to  allow  of  a  view  of  the  drum- 
head, which  was  afterwards  found  to  be  affected.  If  I  had 
been  able  to  exclude  the  non-suppurative  diseases  of  the  canal, 
as  I  have  those  of  the  middle  ear,  the  preponderance  of 
middle  ear  cases  would  have  been  much  greater. 

Symptoms. — A  discharge  of  pus  from  the  ear  is  the  most 
striking  symptom  in  chronic  suppuration  of  the  middle  ear. 
There  can  hardly  be  such  a  thing  as  a  chronic  suppuration  in 
this  part  without  a  perforation  of  the  drum-head,  through 
which  the  pus  escapes.  Such  a  process  may  occur,  however, 
as  will  be  seen  by  reference  to  a  case  recorded  in  the  chapter 
on  the  consequences  of  chronic  suppuration,  where,  although 
pus  had  formed,  and  probably  had  existed  for  weeks  in  the 
mastoid  process,  it  did  not  at  all  involve  the  drum-head.  Such 
cases  are,  however,  very  exceptional.  A  chronic  suppuration 
of  the  middle  ear,  almost  always  involves  an  ulcerative  per- 
foration of  the  membrana  tympani.  When  the  former  term  is 
used,  the  latter  state  of  things  is  understood  to  exist,  what- 
ever other  changes  of  structure  may  have  occurred.  The  dis- 
charge of  pus  is  sometimes  very  profuse  and  constant,  so  that 
it  streams  from  the  ear.  This  is  more  apt  to  be  the  case  in 
young  children.  In  such  cases  the  auricle  and  external  audi- 
tory canal  become  red,  tender,  and  even  excoriated  from  the 
irritation  of  the  pus  in  which  the  parts  are  bathed.  In  other 
and  more  numerous  cases,  the  pus  lies  only  at  the  bottom  of  the 
canal  upon  the  remains  of  the  membrana  tympani  and  in  the 
cavity  of  the  tympanum,  enveloping  the  chain  of  bones,  and 
passing  into  the  cavities  called  the  mastoid  cells.  In  still  other 
cases,  there  is  no  continuous  outflow  of  pus,  either  by  day,  or 
at  night  upon  the  pillow  ;  but  at  intervals  there  is  a  slight  in- 
crease of  the  unpleasant  symptoms,  which  even  assume  the 
dignity  of  an  ear-ache,  after  which  a  free  discharge  of  pus  from 


CHRONIC  SUPPURATION — SYMPTOMS.  367 

the  ear  occurs.  On  questioning  such  patients  in  regard  to  the 
existence  of  a  discharge  from  the  ear,  they  will  usually  state, 
that  none  occurs,  except  after  an  attack  of  ear-ache,  although 
the  fact  is  that  pus  is  always  lying  in  the  part.  If  we  examine 
such  an  ear  when  the  discharge  is  supposed  to  have  ceased, 
we  shall  find  at  the  bottom  of  the  canal,  and  in  the  cavity  of 
the  tympanum,  a  hardened  mass  of  dried  pus  covered  over 
by  cerumen,  or  epidermis.  Impacted  cerumen  is  quite  a  fre- 
quent occurrence  in  the  course  of  a  chronic  suppurative  pro- 
cess in  the  middle  ear.  We  shall  often  come  to  an  erroneous 
conclusion  as  to  the  cause  of  a  loss  of  hearing,  if  we  judge  of 
the  case  from  the  presence  of  hardened  cerumen  in  the  audi- 
tory canal  without  getting  the  history. 

The  membrana  tympani  presents  the  most  varied  appear- 
ance in  different  cases  of  chronic  suppuration  in  the  middle 
ear ;  sometimes,  it  is  entirely  swept  away,  and  all  the  ossicula 
with  it.  The  cavity -of  the  tympanum  is  then  an  empty  cavity 
opening  upon  the  canal.  Again,  there  is  a  rim  remaining, 
with  perhaps  the  incus  and  stapes  in  situ,  or  dislocated,  but 
yet  present,  while  the  malleus  is  gone.  In  other  cases  the 
ossicula  are  intact  and  in  position,  but  there  are  clearly-cut, 
well-defined  holes,  from  one  to  three  in  number,  in  the  drum- 
head. The  chromo-lithographs  exhibit  such  a  perforation, 
with  the  blood-vessels  that  are  about  to  repair  it,  radiating 
towards  the  opening.  Sometimes  one-half  of  the  membrane 
is  cleanly  cut  away.  In  fact,  the  appearance  of  the  mem- 
brane is  as  various  as  the  number  of  cases.  The  description 
of  no  one  case  will  do  for  another. 

"When  we  come  to  the  consideration  of  the  consequences  of 
this  disease,  we  shall  see  that  besides  these  changes  already 
mentioned,  we  often  find  growths  springing  from  the  mucous 
membrane  of  the  tympanic  cavity,  so-called  polypi.  Exostoses 
may  exist  in  the  canal,  or  even  in  the  walls  of  the  tympanic 
cavity ;  the  bone  may  be  exposed,  i.  e.,  denuded  of  its  perios- 
teum, roughened  and  in  a  condition  of  caries.  The  seventh 
nerve,  in  its  passage  through  the  aqueduct  of  Fallopius,  may 
be  destroyed  by  the  morbid  process,  when  the  smirk  of  facial 
paralysis  is  added  to  the  disgusting  detail  of  the  ravages  of 
disease. 


368  PERFORATIONS   OF  MEMBRANA  TYMPANI. 

I  do  not  think  there  is  any  one  point  more  than  another, 
in  the  membrana  tympani,  where  perforations  are  apt  to 
occur.  Sir  William  Wilde,  and  Moos,  quoted  by  Hinton,** 
affirm  that  they  are  most  frequently  situated  in  the  anterior 
and  lower  part  of  the  membrane,  where  the  air  blown  through 
the  Eustachian  tube  impinges.  Hinton  has  seen  quite  as 
many  in  the  inferior  and  posterior  segments,  an  experience 
which  my  own  quite  confirms.  I  have  found  them  in  every 
quadrant  of  the  drum-head. 

Perforations  are  sometimes  so  small  as  not  to  be  easily 
recognized,  unless  air  is  forced  through  the  Eustachian  tube 
and  made  to  pass  through  them.  As  has  been  stated  in  the 
preceding  chapter,  Wilde  thought  that  a  pulsation  at  the  bot- 
tom of  the  auditory  canal  was  pathognomic  of  perforation  of 
the  drum-head.  Where  this  pulsation  occurs,  it  is  a  very 
suspicious  circumstance ;  but,  as  has  been  before  said  in  this 
volume,  a  thin  membrana  tympani,  in  a  state  of  acute  catarrhal 
inflammation,  will  sometimes  exhibit  this  phenomena  when 
the  drum-head  is  intact.  Mr.  Hinton  remarks  in  his  excellent 
paper  on  Perforations  of  the  Membrana  Tympani,  from  which 
I  have  just  quoted,  "  This  motion  (pulsating)  is  imparted  by 
the  blood,  and  implies  not  necessarily  an  aperture,  but  a 
thin  surface  of  fluid  in  contact  with  a  beating  vessel."t  The 
complete  absence  of  the  membrana  tympani,  especially  if 
the  mucous  lining  of  the  tympanic  cavity  have  a  granu- 
lar or  velvety  appearance,  is  often  very  puzzling.  Such 
cases  will  sometimes  require  the  most  careful  cleansing  be- 
fore we  can  determine  how  much,  if  any,  of  the  drum-head 
remains. 

We  need  not  enter  into  any  detailed  account  of  the  condi- 
tion of  the  pharynx  and  Eustachian  tubes  in  the  affection 
now  under  consideration,  since  this  subject  has  been  so  fully 
dwelt  upon  in  treating  of  the  chronic  non-suppurative  inflam- 
mations. It  may  be  sufficient  to  say  here  that  we  find  in 
chronic  suppuration,  as  well  as  in  all  the  varieties  of  inflam- 
mations of  the  middle  ear,  except  the  purely  proliferous  forms, 
that  the  naso-pharyngeal  region  has  been  the  usual  point  of 

*  Guy's  Hospital  Reports,  3d  Series,  vol.  xii. 
f  L.  c,  p.  630. 


ALBUMINURIA  FROM  CHEONTO  SUPPURATION.  369 

origin  of  the  disease,  and  that  any  successful  management  of 
the  ear  will  require  great  attention  to  the  pharynx  and  Eusta- 
chian tube. 

The  general  health  of  a  patient  affected  with  chronic  sup- 
puration of  the  middle  ear  is  usually  impaired,  even  if  none 
of  the  serious  consequences  have  occurred.  Such  a  drain 
upon  the  system  is  not  tolerated  with  equanimity  by  nature. 
Dr.  Hackley*  has  found  albuminaria  in  a  number  of  cases  of 
chronic  suppuration  of  the  middle  ear,  where  there  was  no 
apparent  cause  for  the  disease,  except  the  long-continued 
secretion  of  pus  in  the  tympanic  cavity.  He  is  inclined  to 
think,  that  such  cases  are  analogous  to  those  of  the  develop- 
ment of  lardaceous  kidney  from  debilitating  diseases. 

The  fact  that  a  running  sore  is  detrimental  to  the  con- 
tinuance of  good  general  health,  would  scarcely  need  assertion, 
were  it  not  that  the  author,  in  common  wdth  many  others,  has 
observed  a  very  deeply  rooted  idea  among  the  laity — an  idea 
that  was  first  inculcated,  and  which  is  even  now  encouraged 
by  the  profession — that  there  is  no  harm  resulting  from  a 
chronic  ulcerative  process  in  the  ear,  when  it  is  well  out  of 
sight.  It  is  even  at  times  gravely  asserted  that  such  a  drain 
to  the  system  is  salutary,  as  if  our  Creator  would  not  have 
made  the  human  race  with  such  a  oie  if  it  were  necessary. 
I  have  seen  persons  who  allow  their  ears  to  become  an  offence 
to  the  nostrils  of  those  about  them,  because  they  have  been 
advised  by  their  physician  that  it  was  not  best  to  "  meddle 
with  the  ear."  If  my  reader  feels  that  I  have  said  too  much 
on  this  subject,  in  the  different  parts  of  this  volume,  I  beg 
that  he  will  ask  himself  how  many  cases  of  death  he  has 
known  as  the  result  of  a  suppurative  process  in  the  ear,  to 
consult  his  fellow  practitioners  on  the  same  point,  and  finally 
to  investigate  the  statistical  tables  of  deaf  and  dumb  asylums. 
In  the  answers  to  these  interrogatories  will  be  found  a  com- 
plete justification  of  my  earnestness  on  this  point.  The  anat- 
omy of  the  middle  ear,  showing,  as  it  does,  the  relations  of  this 
small  portion  of  the  organism  to  the  most  important  parts  of 
the  system,  to  the  great  arterial  and  venous  vessels,  to  the 

*  Verbal  communication  at  New  York  Ophthalmological  Society. 

24 


370  NEGLECT  OF  CHRONIC  SUPPURATION. 

nervous  system,  to  the  organs  of  respiration,  is  also  of  itself 
a  sufficient  proof  of  the  necessary  importance  of  a  long-con- 
tinued suppuration  in  this  part. 

There  still  exists,  however,  even  in  the  minds  of  some 
physicians,  a  prejudice  against  the  stoppage  of  a  purulent 
discharge  from  the  ear.  In  the  laity  this  prejudice  is  widely 
spread,  and  is  chiefly  dependent  upon  the  erroneous  teachings 
■  of  the  older  French  writers,  Du  Yerney  and  Itard.  As  Wilde 
shows,  in  his  classic  article  upon  this  disease  in  his  text-book, 
"  because  it  was  observed  that  on  the  supervention  of  cerebral 
disease,  discharges  from  the  auditory  canal  have  lessened, 
practitioners  mistaking  the  effect  for  the  cause,  have  been  led 
to  believe  that  the  sudden  '  drying  up  '  produced  a  metastasis 
to  the  brain,  a  notion  as  crude  as  it  is  unsupported."  There 
is,  I  believe,  no  pathological  experience  on  record  which  can 
sustain  the  quite  common  assertion  that  it  is  dangerous  to 
stop  a  discharge  from  the  ear.  There  are  only  cases  on 
record — of  which  there  are,  alas  !  many  more  than  were  ever 
recorded — where  disease  of  the  brain  has  occurred  from  the 
extension  of  a  neglected  suppuration  to  the  cerebral  mem- 
branes and  substance,  and  the  discharge  from  the  ear  has 
nearly  ceased ;  but  these  certainly  form  no  argument  against 
the  arrest  of  an  ulcerative  process  before  any  parts  beyond 
the  cavity  of  the  tympanum  are  involved. 

He  who  believes  that  we  can  easily  cause  a  discharge  of 
pus  to  cease,  after  caries  of  the  temporal  bone  has  occurred, 
will  find  many  cases  which  will  cause  him  to  doubt  the  effi- 
cacy of  his  therapeutics.  As  well  might  we  refuse  to  heal  an 
ulcerated  hip-joint,  as  to  neglect  to  check  a  discharge  from  a 
diseased  membrana  tympani  or  lining  membrane  of  the  tym- 
panic caTaty. 

It  is  doubtless  true,  judging  from  the  histories  of  cases  and 
the  inspection  of  the  membraua  tympani,  in  which  cicatrices 
occur,  that  many  cases  of  chronic  suppuration  are  cured  with 
very  slight  treatment,  or  with  none  at  all.  The  fact  remains, 
however,  that  the  most  of  the  neglected  cases  do  not  so  re- 
cover, and  after  a  purulent  discharge  from  the  ear  has  once 
set  in,  "  we  can  never  tell,"  to  quote  again  the  words  of  Wilde, 
which  should  be  impressed  upon  the  attention  of  every  prac- 


HEARING  POWER  EST  CHRONIC   SUPPURATION.  371 

titioner  of  medicine,  "  how,  when,  or  where  it  will  end,  or  what 
it  may  lead  to."* 

A  careful  treatment  is  usually  required  to  check  the  dis- 
charge and  treat  the  ulcerated  membrana  tympani,  and  restore 
the  hearing  power.  Even  with  the  most  careful  and  skillful 
treatment,  we  cannot  always  succeed  in  all  of  these  things. 
In  some  rare  cases  we  do  not  succeed  in  any  of  them ;  but  the 
patient,  in  spite  of  our  best  efforts,  will  go  on  to  his  doom. 

The  degree  of  the  impairment  of  hearing,  in  cases  of 
chronic  aural  suppuration,  is  very  variable.  It  depends,  of 
course,  upon  many  factors ;  for  example,  the  condition  of  the 
Eustachian  tube,  and  the  integrity  of  the  structure  in  the 
cavity  of  the  tympanum.  The  hearing  power  by  no  means 
depends  upon  the  presence  or  absence  of  the  membrana  tym- 
pani. The  chief  function  of  this  membrane  is  probably  to 
protect  the  tympanic  cavity,  and  not  to  transmit  the  vibra- 
tions of  the  atmosphere,  which  when  conveyed  to  the  acoustic 
nerve  we  call  sound.  I  know  some  persons  who  have  large 
perforations  in  each  membrana  tympani,  and  who  yet  hear 
well  enough  for  all  the  ordinary  purposes  of  life,  although  not 
with  perfection.  One  notable  instance  of  this  kind  is  that  of 
a  busy  physician  of  my  acquaintance.  As  has  been  already 
said  in  Chapter  XIV.,  Sir  Astley  Cooper,  in  a  paper  published 
in  the  Transactions  of  the  Koyal  Society  in  1800,*  showed 
that  there  could  be  very  good  hearing  powers  with  a  perforate 
membrana  tympani ;  and  yet  I  very  often  hear  the  question 
asked,  as  well  by  physicians  as  by  laymen,  if  anything  can  be 
done  when  there  is  a  hole  in  this  membrane ;  and  it  is  also 
often  stoutly  asserted  that  when  this  membrane  is  once  gone, 
the  hearing  is  irrevocably  lost.  This  false  idea  continues  to 
prevail,  not  only  in  spite  of  scientific  demonstration  of  more 
than  seventy  years  ago,  but  also  in  the  face  of  clinical  facts  that 
are  every  day  within  the  reach  of  each  attentive  physician. 
Truly,  a  lie  will  travel  around  the  world,  while  truth  is  putting 
on  its  boots. 

The  parts  which  form  the  middle  ear  make  up  a  cavity 
which  have  perhaps  as  many,  if  not  more,  important  anatomi- 

*  Text-Book,  p.  407. 

f  Philosophical  Transactions,  1800,  Part  I. 


372  CHRONIC   SUPPURATION — TREATMENT. 

cal  relations  than  any  one  of  similar  size  in  the  human  body. 
The  cavity  of  the  tympanum  is  covered  above  by  a  thin,  rare- 
fied bony  plate,  which  is  in  direct  communication  with  the 
cerebral  meninges  ;  the  floor  is  close  to  the  great  jugular.  Its 
internal  wall  is  the  labyrinth  wall,  with  its  two  fenestra,  cov- 
ered only  by  thin  membrane  and  opening  into  the  ramifica- 
tions of  the  acoustic  nerve  and  the  fluid  which  is  continuous 
with  that  of  the  sub-arachnoid  space ;  while  externally  we  have 
a  membrane  of  about  the  thickness  of  letter-paper. 

Treatment. — The  proper  treatment  of  a  chronic  suppura- 
tion in  such  a  space,  should  be  a  matter  of  the  greatest  solici- 
tude. It  involves  not  alone  the  hearing  power,  but  also  the 
life  of  the  patient.  There  is  one  pre-requisite  to  the  success- 
ful treatment  of  this  affection,  and  that  is,  a  comjjlefe  removal 
of  all  the  morbid  material  that  has  formed  in  the  middle  ear. 
This  is  simply  another  way  of  stating  that  the  parts  must  be 
thoroughly  cleansed. 

As  we  have  seen  in  the  discussion  of  the  various  affections 
of  the  middle  ear,  their  starting-point  is  usually  in  the  fauces 
or  pharynx.  But  the  ulcerative  process  which  has  been  set 
up  in  the  tympanic  cavity  has  broken  through  the  membrana 
tympani,  and  the  result  shows  itself  in  the  external  auditory 
canal.  The  problem  to  be  solved  is,  how  may  we  stop  the 
ulcerative  process,  heal  the  membrana  tympani,  and  restore 
the  hearing  power,  which  has  been  impaired  by  the  inflamma- 
tory process  in  the  sound-conducting  apparatus?  In  many 
cases,  however,  we  may  be  well  satisfied  if  two  of  these  re- 
quirements be  fully  fulfilled,  while  the  hearing  power  is  im- 
proved. A  radical  cure  of  a  suppurative  process  in  the  mid- 
dle ear,  of  long  standing,  is,  from  the  very  nature  of  things, 
sometimes  impossible. 

The  old  method  of  treating  such  a  suppuration  was  to 
advise  the  patient  to  syringe  the  ears  with  soap  and  water, 
put  a  blister  on  the  mastoid  process,  and  at  the  same  time 
the  physician  got  the  system  to  rights  by  using  alteratives, 
laxatives,  and  purgatives.  The  general  principle  of  treatment 
thus  held  in  view  was  correct,  but  in  the  matter  of  the  local 
treatment,  which  is  of  far  more  importance  than  the  constitu- 


CHKONIC  SUPPURATION — TEEATMENT.  373 

tional,  altogether  too  much  was  left  to  the  supposed  knowl- 
edge and  skill  of  the  patient  or  his  attendant. 

Perhaps  not  more  than  one  layman  in  a  hundred  can,  with- 
out instruction,  thoroughly  cleanse  an  ear  by  syringing.  It  is 
generally  thought  that  any  person  can  syringe  an  ear,  when 
the  facts  are  that  no  patient  can  properly  cleanse  his  own  ear, 
and  almost  every  one  requires  instruction  before  he  can  even 
syringe  the  ear  of  another.  In  one  of  the  preceding  chapters 
of  this  book  (see  page  128),  the  proper  method  of  syringing 
has  been  carefully  described,  so  that  we  need  not  dwell  upon 
the  subject  again. 

Sometimes  the  use  of  the  syringe  is  not  well  borne  by  the 
patient,  the  shock  of  the  water  being  too  great.  In  such  cases 
the  aural  douche  of  Clarke,  is  a  good  substitute  for  the  syringe. 
Instead  of  the  thin  bowl  that  I  have  recommended  as  a  recep- 
tacle for  the  fluid  that  comes  from  the  canal,  after  having  been 
injected,  some  practitioners  use  a  vessel  such  as  depicted  in 
the  accompanying  cut — the  "  iter-becher  "  of  the  Germans.    It 

Fig.  72. 


Vessel  used  in  Syringing  the  Ear. 

is  certainly  very  convenient  on  account  of  the  fact  that  it 
adapts  itself  so  well  to  the  glenoid  fossa,  but  it  is  not  deep 
enough  if  any  prolonged  syringing  is  required.  Then  the 
bowl  will  do  better,  and  on  the  whole  I  think  it  is  to  be  pre- 
ferred. 

I  have  known  sad  cases,  where  parents,  in  obedience  to  their 
medical  adviser,  have  faithfully  syringed  the  ears  of  a  child 
suffering  from  chronic  suppuration  for  years,  but  where  the 
parts  have  not  been  perhaps  even  once,  thoroughly  cleansed. 
Exuberant  granulations  or  polypi  had  sprung  up,  bony  growths 
had  occurred,  which  are  positive  evidences  of  the  imperfect 
removal  of  pus  and  other  hurtful  material. 


374  CHRONIC   SUPPUEATION — TREATMENT. 

There  are  several  methods  of  cleansing  ears  affected  with 
a  chronic  suppurative  process.  That  which  I  usually  adopt 
is  a  combination  of  the  suggestions  of  Politzer,  Hinton,  and 
Schwartze.  It  is,  I  think,  a  simple  method,  and  capable  of 
being  fully  carried  out  by  any  practitioner,  but  not  by  the 
patient  or  a  nurse.  The  personal  care  and  supervision  of  a 
medical  man  is  necessary  to  the  successful  treatment  of  any 
case  of  chronic  suppuration  in  the  ear.  This  personal  care 
need  not  always  be  daily,  although  it  is  better  to  have  it  so ; 
but  it  should,  at  the  very  least,  be  given  twice  a  week,  while 
the  attendant  of  the  patient  is  instructed  as  well  as  may  be, 
for  the  performance  of  the  duty  of  cleansing  the  ear  in  the 
intervening  time.  The  importance  of  the  cases  for  which  the 
daily  attendance  of  the  physician  is  required,  if  properly  set 
forth,  will  do  away  with  any  objections  that  may  be  made. 
No  one  certainly  would  object  to  the  daily  attendance  of  a 
physician  upon  a  case  of  suppuration  of  the  cornea,  and  I 
submit  that  a  suppuration  in  the  cavity  of  the  tympanum  and 
membrana  tympani  is  of  equal  importance,  with  the  disease 
of  the  organ  of  vision. 

The  method  I  usually  adopt  is  the  following  :  The  ear  is 
first  carefully  cleansed  with  lukewarm  water  by  means  of  a 
good  hard-rubber  syringe.  The  bowl  to  contain  the  water 
coming  from  the  ear,  should  be  held  by  the  patient  himself 
— unless  a  very  young  child  be  the  subject — and  well  into  the 
glenoid  fossa,  when  no  water  will  be  spilled.  After  this  the 
ear  is  filled  with  lukewarm  water  poured  from  a  test  tube, 
a  spoon,  or  the  like,  and  the  meatus  carefully  stopped  by  a 
bit  of  cotton-wool.  The  Eustachian  tube  is  then  inflated  by 
means  of  Politzer's  method,  and  to  such  an  extent  that  a  few 
drops  of  the  water  are  forced  by  the  side  of  the  cotton  out  of 
the  canal.  This  is,  of  course,  conclusive  evidence  that  the  air 
has  been  forced  through  the  tube  into  the  middle  ear,  and 
through  the  hole  in  the  drum-head  into  the  external  canal. 
The  ear  is  again  carefully  syringed  and  examined  by  the  sur- 
geon. At  the  beginning  of  such  a  treatment,  especially  in 
chronic  cases,  small  portions  of  inspissated  or  glutinous  mate- 
rial will  still  be  found.  These  should  be  then  thoroughly 
removed  under  a  good  illumination  from  a  mirror  upon  the 


CHKONIC   SUPPUEATTON — TKEATMENT.  375 

forehead,  by  means  of  a  cotton-holder,  which  is  simply  a  slen- 
der steel  probe,  roughened  at  one  extremity.  In  the  absence 
of  this  instrument,  a  thin  bit  of  wood,  or  a  match,  about 
which  cotton  is  carefully  twisted,  will  do  very  well. 

Having  satisfied  ourselves  by  inspection  with  the  otoscope 
that  the  ear  is  thoroughly  cleansed,  the  warm  astringent  solu- 
tion should  be  poured  into  the  ear,  and  allowed  to  remain  for  a 
period  varying  from  five  to  fifteen  minutes.  If  the  membrana 
tympani  be  nearly  gone,  the  solution  may  be  swabbed  about 
the  bottom  of  the  ear  by  means  of  the  cotton-holder,  used 
under  the  illumination  of  the  mirror  on  the  forehead. 

The  choice  of  an  astringent  is  perhaps  not  so  important 
as  is  often  supposed.  I  usually  use  the  sulphate  of  zinc  for 
comparatively  recent  cases,  and  the  nitrate  of  silver  for  old 
ones.  The  sulphate  of  zinc  should  be  used  in  weak  solutions 
— from  1  to  4  grains  to  the  ounce — and  the  nitrate  of  silver  in 
strong  ones.  Nitrate  of  silver  seems  to  be  of  no  value  in  these 
cases,  unless  used  of  the  strength  of  40  grains  to  the  ounce. 
It  may  be  even  used  as  strong  as  480  grains  to  the  ounce. 
Dr.  O.  D.  Pomeroy,  of  this  city,  reports  a  case*  of  "suppura- 
tive inflammation  of  the  tympanic  cavity,  with  subjective 
symptoms  of  mastoid  inflammation,"  where,  after  using  solu- 
tions of  from  40  to  80  grains,  he  finally  used  the  very  strong 
one  of  480  grains  to  the  ounce  of  water.  "  It  caused  a  slight 
feeling  of  warmth  and  fulness  in  the  ear,  but  not  real  pain. 
The  discharge  was  entirely  arrested  by  this  one  application." 
The  membrane  was  found  to  be  healed  on  an  examination 
made  some  six  months  afterward. 

In  Schwartze's  paper  calling  attention  to  the  use  of  the 
nitrate  of  silver,  in  what  he  regards  as  strong  solutions,  he 
advises  against  the  instillation  of  nitrate  of  silver  where  gran- 
ulations or  disease  of  the  bone  exists.  His  exact  words  are  : 
"  The  caustic  treatment  only  promises  a  nearly  certain  result, 
when  we  may  exclude  with  positiveness  the  existence  of  gran- 
ulations upon  the  exposed  mucous  membrane,  or  upon  the 
remains  of  the  membrana  tympani,  and  when  there  are  no 
evidences  of  ulceration  of  the  bone."  f 

*  New  York  Medical  Journal,  Dec.  1872,  p.  631. 
f  ArcMv  fur  Ohrenheilkunde,  Bd  IV.,  p.  2. 


376  CHEONIC   SUPPURATION — TREATMENT. 

The  experience  of  American  otologists,  has  been  that  strong 
solutions  of  nitrate  of  silver  may  be  safely  and  profitably  used, 
even  where  there  are  granulations  and  polypi.  Indeed  I  would 
especially  recommend  it  for  some  of  these  cases,  although  I 
admit  that  their  value  is  often  strikingly  seen  in  obstinate 
cases  of  chronic  suppuration,  where  the  membrane  is  not  yet 
in  what  may  be  termed  a  very  proliferous  condition.  It  is 
not  necessary  to  neutralize  the  solution  by  the  use  of  salt  and 
water. 

An  efficient  method  of  applying  nitrate  of  silver  to  the 
whole  mucous  tract  of  the  middle  ear,  at  least  to  the  lining  of 
the  cavity  of  the  tympanum  and  the  Eustachian  tube,  is  the 
following  :  The  solution  is  dropped  into  the  cavity  of  the  tym- 
panum through  the  external  meatus,  and  then  forced  through 
into  the  tube  by  two  or  three  puffs  from  the  ordinary  air-bag 
used  in  Politzer's  method.  Of  course  the  patient  will  taste  the 
nitrate  of  silver,  if  it  be  used  in  this  manner. 

Mr.  James  Hinton,  of  London,  recognizing  the  fact  upon 
which  I  have  laid  so  much  stress,  that  thorough  cleansing  of 
the  ear  is  the  first  requirement  of  all  treatment  of  chronic  sup- 
puration in  this  part,  advises  the  forcible  syringing  of  the 
tympanic  cavity,  by  means  of  a  syringe  whose  nozzle  is  made 
to  fit  into  the  external  meatus,  so  as  to  exclude  all  the  exter- 
nal air.  He  also  syringes  the  tympanic  cavity  through  the 
Eustachian  tube,  and  uses,  both  for  this  external  and  internal 
syringing,  solutions  of  carbonate  of  soda,  say  of  twenty  grains 
to  the  ounce.  I  believe  this  latter  method  of  washing  out  the 
cavity  of  the  tympanum,  was  revived  and  applied  to  cases  of 
suppuration,  by  Dr.  Millinger,  of  Vienna.  I  have  found  the 
washing  out  of  the  middle  ear,  with  the  solution  of  soda,  a 
very  useful  adjuvant  in  these  obstinate  cases  now  under  con- 
sideration ;  for  it  must  always  be  borne  in  mind,  if  we  would 
avoid  great  disappointment,  that  these  cases  are  usually 
obstinate,  and  often  trying  to  the  patience  of  the  practitioner. 
I  cannot  say  very  much  for  the  method  of  forcing  fluid  into 
the  auditory  canal,  with  the  nozzle  of  the  syringe  placed  her- 
metically into  the  meatus.  I  sometimes  resort  to  it ;  but  I 
have  usually  found  it  rather  violent  in  its  action,  as  it  is  apt 
to  cause  dizziness  and  vertigo. 


CHRONIC  SUPPURATION — TREATMENT.  377 

It  is  necessary  and  proper,  in  some  cases  that  have  resisted 
less  active  treatment,  to  apply  the  solid  nitrate  of  silver  to  the 
edges  of  the  perforated  membrana  tympani,  as  well  as  to  the 
tympanic  cavity.  It  is  best  applied  on  a  probe,  upon  the 
point  of  which  it  has  been  fused,  in  a  platinum,  cup  placed 
over  a  lighted  lamp  or  gas-burner.  This  treatment,  unlike  the 
others,  is  apt  to  cause  pain,  which  usually  passes  away  on 
pouring  warm  water  into  the  ear.  It  is  a  method,  however, 
only  to  be  resorted  to  when  other  means  fail. 

I  have  not  found  powders  useful  in  checking  chronic  sup- 
purations of  the  ear.  They  usually  act  as  foreign  bodies,  and 
fly  up  the  meatus.  There  is  a  story  told  of  an  itinerant  quack, 
who  stopped  discharges  from  the  ear  by  filling  the  ear  with 
plaster  of  Paris  in  a  fluid  state.  Its  hardening  would  certainly 
prevent  any  emergence  of  pus  for  some  time. 

As  has  been  before  said,  the  cleansing  of  the  ear  by  the 
medical  attendant  should  be  performed  about  three  times  a 
week.  If  the  suppuration  be  profuse,  the  patient  should  be 
seen  daily.  Here,  as  in  other  departments  of  otology,  we  meet 
with  great  prejudice  on  the  part  of  the  laity.  They  have  been 
so  accustomed  to  be  sent  off  with  a  prescription  for  a  "  run- 
ning from  the  ear,"  that  they  are  quite  amazed  at  being  asked 
to  come  to  the  office  daily,  or  three  times  a  week.  Yet  this 
will  often  be  necessary,  and  here  as  elsewhere  there  remains 
some  pioneer  work  to  be  done  in  the  education  of  the  people. 

Dr.  Beard,*  of  this  city,  believes  that  the  galvanic  current 
is  sometimes  a  powerful  adjuvant  in  healing  a  suppurative 
process  in  the  middle  ear,  just  as  it  is  in  healing  ulcers  in 
other  parts  of  the  body.  An  electrode  with  a  long  narrow 
extremity,  covered  with  a  little  cotton,  is  passed  into  the  audi- 
tory canal  through  a  rubber  speculum.  The  canal  is  usually 
filled  with  warm  water.  The  electrode  is  connected  with  the 
negative  pole  of  the  battery.  The  positive  pole  is  placed  either 
in  the  hands  of  the  patient  or  at  the  back  of  the  neck.  Only 
very  weak  currents  and  short  applications  are  borne,  and  the 
treatment  should  be  cautiously  conducted.  Drs.  Mathewson 
and  Prout,  in  conjunction  with  Dr.  Beard,  have  been  testing 

*  Verbal  communication. 


378  CHOICE  OP  ASTKINGENTS. 

the  plan  of  treatment,  in  cases  at  the  Brooklyn  Eye  and  Ear 
Hospital.  The  character  of  the  discharge  soon  begins  to 
change  under  this  treatment,  and  in  some  cases  the  cure 
seems  to  have  been  more  speedy  than  it  would  have  been 
without  it. 

Dr.  C.  I.  Pardee,*  of  this  city,  believes  that  the  choice  of  an 
astringent  may  be  regulated  by  the  character  of  the  secretion. 
If  the  secretion  from  the  exposed  tympanic  cavity  be  pre- 
dominantly of  a  mucous  character,  Dr.  Pardee  uses  nitrate  of 
silver.  When  the  secretion  is  chiefly  purulent,  he  uses  weak 
astringents  of  sulphate  of  zinc,  acetate  of  lead,  and  alum.  It 
would  certainly  be  a  great  advance  did  we  have  more  certain 
indications  for  the  use  of  strong  or  weak  astringents  ;  but  I  am 
not  prepared  to  give  a  positive  opinion  as  to  the  correctness 
of  Dr.  Pardee's  theory.  I  may  only  repeat,  what  was  said  in 
substance  in  the  preceding  part  of  this  chapter,  that  any  of 
the  well  known  mineral  astringents  do  very  well,  if  the  parts 
are  thoroughly  cleansed,  and  if  none  of  the  consequences  of  the 
suppurative  process  have  as  yet  resulted.  It  should  not  be 
forgotten  that  the  pharynx  and  nostrils  will  often  require 
nearly  as  much  treatment  as  the  ear. 


THE  ARTIFICIAL  MEMBRANA  TYMPANI. 

This  contrivance  is  at  times  a  valuable  means  of  treating 
a  chronic  suppurative  process  in  the  middle  ear.  We  have 
already,  on  page  43,  seen  that  a  New  York  layman  was  the 
actual  inventor  of  a  substitute  for  the  natural  membrane. 
This  gentleman  used  a  bit  of  paper  moistened  with  saliva  for 
this  purpose  in  his  own  ear,  and  showed  it  to  Dr.  James 
Yearsley  of  London,  who  seized  upon  the  idea,  and  gave  it  to 
the  profession,  substituting  cotton-wool  for  the  paper.  Besides 
acting  as  an  artificial  membrane,  the  cotton-plug  is  sometimes 
used  as  a  means  of  treating  a  chronic  suppurative  process  in 
the  ear.  It  is  then  packed  in  the  canal  quite  thoroughly. 
When  it  is  employed  for  the  purpose  of  improving  the  hear- 

*  Transactions  of  American  Otological  Society,  Fourth  Annual  Meeting, 
1871. 


AETIFICIAL  MEMBRANA   TIMPANI.  379 

ing,  having  been  slightly  moistened,  it  is  inserted  under  in- 
spection— that  is,  while  the  parts  are  well  illuminated  by  the 
otoscope — by  means  of  a  pair  of  forceps,  that  should  be  very 
weak  in  the  spring,  so  that  the  blades  may  come  together 
with  very  little  pressure.* 

The  appropriate  position  for  the  cotton  where  it  will  im- 
prove the  hearing,  will  be  found,  if  it  is  to  do  any  good,  by 
placing  it  on  different  parts  of  the  exposed  tympanic  cavity, 
or  the  remains  of  the  drum-head,  until  the  patient  experiences 
an  improvement  in  the  hearing  power.  I  have  seen  several 
patients  who  used  this  kind  of  an  artificial  membrana  tym- 
pani,  and  who  were  very  skillful  in  its  employment.! 

In  1853,  Toynbee  suggested  another  artificial  membrana 
tympani,  without  knowing  of  the  previous  invention.  Toyn- 
bee's  appliance  consists  of  a  thin  disk  of  vulcanized  rubber,  in 

Fig.  73. 


Toynbee's  Artificial  Membrana  Tympani. 

the  centre  of  which  is  attached  a  fine  wire  about  an  inch  long, 
which  terminates  in  a  little  ring,  to  enable  the  finger  to  more 
readily  grasp  it  when  its  removal  is  desired.  An  improvement 
upon  the  original  method  of  attachment  of  the  wire,  is  to 
insert  it  spirally  into  the  disk,  like  a  cork-screw  in  a  cork. 

"We  can  never  tell  without  trial,  whether  the  artificial  mem- 
brana tympani  will,  or  will  not  improve  the  hearing.     Inas- 

*  Yearsley  on  Deafness,  p.  245. 

t  An  artificial  membrana  tympani  was  employed  more  than  two  hundred 
years  before  Yearsley,  but  not  for  the  purpose  of  improving  the  hearing.  Marcus 
Banzer,  in  1640,  recommended  for  this  purpose  a  tube  of  elk's  claw,  which  was 
covered  by  a  piece  of  pig's  bladder.  Leschevin  in  1763,  Autenreith  in  1815, 
and  Lincke  in  1840,  continued  to  employ  such  an  appliance.  Lincke  used  thin 
silver  or  gold  tubes,  somewhat  conical  in  shape,  from  five  to  eight  lines  in 
length,  and  of  from  two  to  three  lines  in  thickness.  The  outer  end  of  the  tube 
had  a  rim  to  prevent  it  from  slipping  too  far  into  the  meatus.  The  inner  end 
was  covered  by  a  thin  piece  of  gold-beater's  skin,  which  was  varnished. — 
Lincke's  Handbuch,  p.  447. 


380 


AKTTFICIAL  MEMBKANA  TYMPANI. 


mucli  as  I  am  sometimes  asked  if  an  artificial  membrana  tym- 
pani  will  do  any  good,  if  the  membrane  be  intact,  it  may  be 
as  well  to  state,  that  it  is  only  of  service  in  cases  of  partial  or 
complete  loss  of  the  drum-head*  Yon  Troltsch  relates  a  case 
of  a  deaf  judge  who  used  to  improve  his  hearing  temporarily 
by  pressing  upon  the  membrana  tympani  with  a  probe ;  but  I 
have  never  been  able  to  increase  the  hearing  power  by  any 
similar  procedure  upon  a  membrana  tympani  that  was  com- 
plete. The  improvement  to  the  hearing  that  does  sometimes 
occur  when  the  cotton  wool,  or  the  membrane  of  Toynbee  is 
used,  is  probably  due  to  the  restoration  of  the  interrupted 

Pig.  74. 


Method  of  Inserting  Artificial  Membrana  Tympani.— Toynbee. 


continuity  of  the  ossicula  auditus  to  the  fenestra  ovalis  and 
the  labyrinth.  Toynbee,  explained  its  benefit  by  stating  that 
it  occurred  as  a  result  of  the  closure  of  the  membrane ;  but 
this  has  been  shown  to  be  an  erroneous  explanation.  Cases 
have  been  seen  where  the  perforation  was  not  closed  by  the 
artificial  membrane,  and  yet  great  improvement  to  the  hear- 
ing resulted  from  its  use.  When  the  patient  first  begins  to 
wear  this  membrane,  it  should  be  used  but  for  a  very  short 


CHRONIC   SUPPURATION — PROGNOSIS.  381 

time  during  the  day.  It  is  always  a  foreign  body,  and  hence  it 
is  liable  to  produce  irritation  and  increase  the  suppurative  pro- 
cess. Lest  any  should  think,  that  the  artificial  membrane  is 
not  a  practical  and  valuable  means  of  alleviating  some  cases, 
I  may  state  that  I  have  now  under  observation  five  patients, 
for  whom  I  first  introduced  the  membrane,  who  have  worn  it 
for  years,  with  uninterrupted  benefit  to  the  hearing  power.  I 
have  taught  several  other  persons  to  apply  the  membrane, 
and  with  benefit ;  but  inasmuch  as  I  have  not  seen  them  for  a 
long  time,  it  is  not  quite  certain,  although  probable,  that  they 
are  still  using  the  substitute  for  the  natural  membrane.  I  am 
in  the  habit  of  tentatively  applying  the  artificial  membrana 
tympani  in  all  old  cases  of  chronic  suppuration  in  the  middle 
ear,  when  the  loss  of  hearing  is  very  great.  If  one  ear  be 
sound,  so  that  the  hearing  for  ordinary  purposes  is  very  good, 
as  it  always  is  under  such  circumstances,  it  is  not  worth  while 
to  use  the  artificial  drum-head  for  the  diseased  ear.  An  ex- 
cessive inflammatory  action  in  the  remains  of  the  drum-head, 
or  in  the  middle  ear,  precludes  any  use  of  the  artificial  mem- 
brane. The  patient  for  whom  it  is  to  be  employed,  should 
also  be  an  adult,  and  possessed  of  a  considerable  amount  of 
intelligence.  It  is  not  of  any  use  in  the  case  of  children,  or 
of  unusually  heedless  or  stupid  adults.  The  wire  to  which  the 
disk  is  attached,  sometimes  becomes  separated  in  removing 
the  membrane,  and  the  disk  of  rubber  is  left  behind.  This 
accident,  although  a  very  insignificant  one — for  the  disk  is 
readily  removed  by  syringing — is  very  apt  to  frighten  the 
patient,  unless  he  has  been  previously  warned  not  to  be  dis- 
turbed if  such  an  accident  occur,  and  not  to  allow  any  im- 
proper attempts  to  remove  such  a  foreign  body. 

Prognosis. — The  prognosis  in  chronic  suppuration  of  the 
middle  ear  depends  upon  a  variety  of  local  and  constitutional 
symptoms.  If  the  consequences  of  chronic  suppuration  have 
occurred,  such  as  exfoliation  and  death  of  bone,  the  formation 
of  polypi,  exostoses  and  so  on,  the  treatment  is  apt  to  be  pro- 
longed, and  in  some  cases,  may  never  be  entirely  or  even  par- 
tially successful.  Again,  when  the  membrana  tympani  is 
entirely  removed,  and  one  or  more  of  the  ossicula  lost,  the 


382  CHRONIC   SUPPURATION — PROGNOSIS. 

prognosis  is  grave.  Yet  the  membrana  tympani  has  a  regen- 
erative power  second  to  that  of  no  other  membrane  of  the 
body.  I  have  repeatedly  seen  it  entirely  restored  after  all 
but  a  narrow  rim  had  been  entirely  swept  away.  This  has 
occurred  at  times  in  cases  of  long  standing.  The  prompt 
healing  of  the  drum-head  after  operative  perforation  and  in 
acute  inflammation,  is  a  matter  of  common  experience. 

The  state  of  the  general  system  will  also  at  times  influence 
the  prognosis  to  a  marked  degree.  Patients  with  phthisis 
pulmonalis  seldom  recover  from  a  spontaneous  rupture  of  the 
membrana  tympani.  The  physician  will  find  ample  material 
for  general  advice  in  some  cases,  and  yet  there  are  many  in 
which  local  treatment  only  is  required ;  while  it  is  essential 
in  all.  "We  may  say,  on  the  whole,  that  the  prognosis  can 
never  be  decidedly  given,  so  long  as  the  membrana  tympani 
is  open,  for  this  membrane  is  essential  to  the  safety  of  the  oar 
from  renewed  attacks  of  acute  suppuration.  All  our  efforts 
should  be  directed,  therefore,  to  closing  up  this  opening. 
There  can  be  no  danger  from  closing  it  too  soon.  Our  chief 
difficulty  will  be  in  closing  it  at  all.  If  regular  and  careful 
treatment  by  a  physician,  continued  for  months,  fails  to  close 
the  opening,  or  to  cause  the  discharge  of  pus  to  cease,  the 
patient  may  perhaps  be  given  up,  as  one  for  whom  there  is  no 
hope  of  cure.  The  family  and  friends  should  be  taught  to 
cleanse  the  ear  thoroughly,  as  long  as  any  purulent  forma- 
tion occurs,  and  they  should  know  that  the  chief  danger  to 
the  ear,  and  the  general  system,  lies  in  an  accumulation  and 
retention  of  pus. 

CASES. 

Case  I. — Chronic  Suppuration  of  twelve  pears  standing— Exostosis  of  Tym- 
panic Canty — Patient  under  treatment  for  more  than  three  years — Both 
Membrana,  Tympani  healed — Hearing  distance  remains  the  same. 

W.  P.  H.,  set.  32.  June  1869.  History — Ten  or  twelve  years  ago,  from 
some  cause  to  patient  unknown,  the  right  ear  began  to  discharge,  and  then 
the  left.  They  have  discharged  at  intervals  ever  since.  Occasionally  there  is 
pain  in  the  ear. 

The  hearing  distance  is — E.,  \ | ;  L.,  -£%.  The  right  membrana  tympani  is 
in  a  state  of  ulceration  ;  about  one-third  is  gone.     The  lower  and  posterior 


CHRONIC  SUPPURATION — CASES.  383 

quadrant  remains.  Considerable  pus  lies  in  the  cavity  of  the  tympanum. 
The  left  membrane  is  nearly  gone.  There  is  a  small  granulation  springing 
from  the  cavity  of  the  tympanum.     The  pharynx  is  tolerably  healthy. 

The  patient  was  ordered  to  use  the  warm  douche  daily.  He  visited  me 
three  times  a  week,  when  the  ears  were  cleansed  by  the  syringe  and  warm 
water,  and  Politzer's  method,  and,  an  astringent,  usually  the  sulphate  of  zinc, 
was  instilled.  In  November,  in  about  four  months  from  the  time  of  my  first 
seeing  him,  the  left  membrana  tympani  had  healed.  The  granulation  disap- 
peared with  no  other  treatment  than  the  cleansing  and  the  use  of  an  astringent. 
March  17,  1870 — The  right  membrana  tympani  now  exhibits  a  clearly  cut 
opening  in  the  posterior  and  inferior  quadrant.  A  small  amount  of  pus  oozes 
from  it.  A  minute  but  positive  elevation  of  bone  comes  out  to  the  opening. 
The  hearing  is  at  times  very  poor,  on  account  of  the  blocking  of  the  tympanic 
cavity  by  pus.  The  patient  has  been  under  my  observation  ever  since  first 
note,  often  coming  to  the  office  every  day.  Nitrate  of  silver,  nitric  acid, 
various  astringents,  with  the  continuance  of  the  douche  and  syringe,  have 
been  employed  in  vain.  March  17, 1871 — The  patient  has  just  passed  through 
an  attack  of  acute  catarrh,  induced  by  taking  cold.  The  hearing  distance 
became  -4a8-  during  this  attack.  Leeches  were  used,  and  subsequently  the 
catheter,  steam  being  passed  through  it.  After  the  subsidence  of  the  inflam- 
mation, the  opening  in  the  membrana  tympani  was  found  to  be  very  much 
smaller.  It  was  then  cauterized  with  the  mitigated  stick  of  nitrate  of  silver/ 
melted  upon  a  probe,  and  in  a  few  weeks  it  healed  entirely  ;  so  that  in  October, 
1872,  he  was  dismissed,  with  H.  D.  R.,  Jf  ;  L.,  /8-,  and  both  drum  membranes 
healed. 


I  have  not  attempted  to  give  the  full  notes  of  this  interest- 
ing but  tedious  case.  I  have  inserted  it  to  show  what  perse- 
verance on  the  part  of  the  patient  will  finally  accomplish  in 
some  cases  of  chronic  suppuration.  There  were  no  peculiar 
means  of  treatment  adopted  during  the  three  years  the  patient 
was  under  my  care  ;  but  he  was  informed  that  it  might  require 
years  to  heal  the  drum-heads.  He  realized  the  danger  from 
a  continued  suppuration,  as  well  as  the  inconvenience  and  dis- 
comfort, and  he  determined  never  to  give  up  the  attempt  to 
cure  it.  Very  few  patients  will  submit  to  such  a  prolonged 
observation  or  treatment  without  faltering  in  their  allegiance 
to  their  medical  adviser. 


Case  II. — Suppuration  in  loth  Tympanic  Cavities  for  fifteen  years,  a  result  of 
the  Pharyngeal  Inflammation  of  Scarlet  Fever — No  treatment  since  first 
attack — Healing  of  one  Drum-head,  with  great  improvement  to  hearing 
power — Other  Membrane  still  open. 

Mr.  A.,  eet.  26.     Nov.  1870— Since  patient  was  11  years  old,  when  he  had 


384  CHRONIC    SUPPURATION — CASES. 

scarlet  fever,  he  has  had  a  discharge  from  hoth  ears,  with  great  impairment 
of  hearing.  Hearing  distance,  right  ear,  -/-s- ;  left,  -4V-  The  membranse  tym- 
pani  on  each  side  are  removed  by  ulceration.  There  is  a  large  amount  of  pus 
in  each  canal,  with  granulations  which  bleed  readily. 

The  ears  were  treated  by  the  warm  douche,  the  syringe,  and  Politzer's 
method  of  inflation.  The  latter  at  once  improved  the  hearing,  so  that  the 
watch  was  heard  at  4  inches,  -£g,  on  the  left  side.  Some  inflammatory  reaction 
was  caused  in  a  few  days  by  the  cleansing  process,  and  the  douche  only,  could 
be  employed.  The  patient  was  seen  from  once  to  twice  a  week,  and  used  the 
douche  and  an  astringent  at  home.  One  year  after,  his  hearing  distance  was, 
R.,  -4as- ;  L.,  f£.     The  left  membrana  tympani  has  just  healed. 

April  16,  1872,  or  nearly  a  year  later,  having  been  seen  at  longer  or  shorter 
intervals  ever  since,  and  having  kept  up  the  treatment  at  his  home,  the  hear- 
ing distance  of  left  ear  is  |f.  The  patient  has  still  occasional  attacks  of  sub- 
acute suppuration  from  right  ear.  His  hearing  power  for  conversation  is 
excel]  ent,  and  no  true  pus  is  found  in  right  tympanic  cavity,  but  some  stringy 
mucus  is  forced  out  by  Politzer's  method.  January,  1873 — The  patient  is 
still  seen  at  long  intervals.     The  condition  of  the  ears  remains  about  the  same. 

Case  III. — Suppuration  of  both  Middle  Ears,  occurring  without  pain — Half 
of  each  Membrana  Tympani  gone — Moderate  amount  of  pus  secreted — 
Treatment  did  not  avail  to  improve  the  Hearing  Power — Artificial  Mem- 
brana Tympani  used  with  benefit. 

E.  R.  T.,  set.  28.  Nov.  1872 — Three  months  since,  patient  found,  on 
awaking  in  the  morning,  that  both  ears  were  discharging.  There  was  no 
pain  experienced  in  them.  He  had  had  naso-pharyngeal  catarrh  for  some 
time,  which  had  been  treated  regularly  by  the  use  of  the  nasal  douche  and 
the  posterior  nares  syringe.  The  patient  is  not  in  very  good  general  health. 
He  has  had  a  pulmonary  hemorrhage,  and  evidently  has  phthisis  pulmo- 
nalis.  He  hears  the  watch  six  inches  on  the  right  side,  two  inches  on  the 
left.  Hearing  distance,  R.,  -4fi8- ;  L.,  -4a8-.  The  pharynx  is  granular.  The 
anterior  and  inferior  quadrant  of  the  membrane  is  gone.  The  remainder 
of  the  membrane  is  white,  and  does  not  reflect  light.  The  left  membrane 
also  has  a  large  perforation,  the  anterior  half  being  absent,  and  the  remain- 
der of  the  membrane  looking  like  the  right.  There  is  a  moderate  amount 
of  pus  secreted  in  the  tympanic  cavity.  The  auditory  canals  are  red  and  sen- 
sitive. The  patient  has  already  had  more  or  less  systematic  treatment,  and  he 
cleanses  his  ears  daily  by  syringing.  There  are  great  variations  in  the  hearing 
power. 

The  patient  was  seen  daily  for  some  six  weeks,  and  efforts  made  to  heal  the 
membrana  tympani  by  the  use  of  sulphate  of  zinc,  alum,  sulphate  of  copper, 
nitrate  of  silver,  in  solution  and  in  solid  form.  Cod-liver  oil  was  given,  and  the 
general  condition  improved,  but  the  membranse  tympani  did  not  heal  in  the 
slightest,  although  the  discharge  was  lessened,  and  the  condition  of  the  audi- 
tory canals  was  improved. 

February  15,  1873. — The  patient's  hearing  power  continued  to  grow  worse, 
when  the  artificial  membranse  tympani  were  inserted,  with  immediate  benefit 


CHRONIC   SUPPURATION — CASES.  385 

to  the  hearing  power,  so  that  he  could  transact  his  business,  which  was  that 
of  a  commercial  traveller.     Hearing  distance,  R.,  -4e8- ;  L.,  /8-. 

April  15. — The  patient  is  still  wearing  the  membranes  with  the  same 
benefit.  The  ears  are  daily  cleansed  by  syringing,  and  an  astringent  is  dropped 
upon  them.  Mr.  T.  says  that  he  cannot  hear  "  at  all "  without  the  artificial 
membranes. 

It  has  been  a  common  observation  with  the  patients  who 
use  an  artificial  membrana  tympani,  that  they  cannot  hear  as 
well  after  removing  the  artificial  drum-heads,  as  they  did 
before  wearing  them.  Yet  in  some  cases,  the  improvement 
continues  for  hours  after  they  are  removed.  The  latter  effect 
is  probably  due  to  the  fact  that  the  restored  continuity  of 
the  ossicula  and  the  fenestra  ovalis  is  kept  up,  even  after  the 
agent  that  caused  the  restoration  is  removed. 

Case  IV. — Chronic  Suppuration  of  ten  years  duration  stopped  in  three  days, 
by  the  removal  of  a  small  granulation  through  the  Drum-head,  and  the 
application  of  nitrate  of  silver — Hearing  power  improved. 

R.  R.,  Nov.  8, 1872,  sent  to  me  by  Dr.  H.  C.  Eno.  When  the  patient  was 
16  years  old  he  "got  cold  in  the  right  ear;"  the  ear  was  very  painful ;  it  dis- 
charged and  has  continued  to  do  so  ever  since.  It  has  been  under  careful  treat- 
ment for  some  months,  and  does  not  discharge  as  much  as  it  did.  The  hear- 
ing distance  is  —. 
4o 

On  examination,  a  slight  amount  of  pus  is  found  upon  the  membrana  tym- 
pani. On  removing  this,  a  small  granulation  is  seen  to  come  through  the 
membrane  in  the  anterior  and  inferior  quadrant. 

November  9. — The  granulation  was  removed  by  means  of  a  pair  of  angular 
forceps.  A  solution  of  nitrate  of  silver,  gr.  40  ad  §  j,  was  applied  in  the  open- 
ing, after  a  thorough  cleansing  of  the  ear  by  syringing  and  Politzer's  method. 

November  10. — The  opening  in  the  membrane  has  closed.  The  patient 
remained  under  observation  until  Nov.  22,  and  suppuration  did  not  again 
occur.    The  hearing  distance  became  -4A8-. 

It  may  be  thought  that  these  cases  illustrate  the  bright 
side  of  the  treatment  of  chronic  suppuration  ;  but  I  do  not 
think  they  are  any  more  than  average  specimens  of  cases  of 
simple  ulceration,  that  is,  ulcerations  unattended  by  death  of 
bone.  When  caries  or  necrosis  of  any  part  of  the  walls  of 
the  cavity  has  occurred,  the  prognosis  is  very  unfavorable 
for  a  perfect  arrest  of  the  morbid  process.  I  have  not  found 
so  much  difficulty  in  relieving  uncomplicated  cases  of  chronic 
suppuration,  as  in  finding  patients  who  were  patient  enough 


386  CHKONIC  SUPPURATION — CASES. 

to  submit  to  the  tedious  treatment  necessary  to  a  cure.  Dis- 
trust of  the  advice  of  the  profession  is  nowhere  more  common 
than  in  cases  of  chronic  suppuration,  in  regard  to  which  the 
laity  have  been  taught  two  erroneous  and  contradictory  doc- 
trines, first,  that  a  discharge  from  the  ear  is  seldom  checked ; 
second,  that  it  is  dangerous  to  arrest  it,  if  we  can. 


CHAPTER    XVII. 

THE  CONSEQUENCES  OF  CHRONIC  SUPPURATION  OP  THE 
MIDDLE  EAR. 

If  a  chronic  suppurative  process  in  the  middle  ear  re- 
mained a  simple  ulcer,  with  none  of  the  consequences  that  are 
very  liable  to  result  from  it,  it  would,  perhaps,  be  a  condition 
of  things  to  be  preferred  to  a  chronic  proliferous  process  in  the 
same  part.  For  in  simple  chronic  ulceration  the  hearing  power 
is  often  very  good,  the  tinnitus  aurium  is  not  usually  exces- 
sive, and  sometimes  does  not  exist,  and  it  may  generally  be 
relieved  by  simple  syringing  and  inflation  of  the  ear.  These 
are  the  symptoms  which  are  so  trying,  in  the  non-suppurative 
form  of  disease,  that  people  have  become  insane  on  account 
of  them.  But  the  almost  inevitable  consequences  of  chronic 
suppuration  in  the  middle  ear,  are  dangerous  to  the  health  and 
life  of  the  patient.  Hence  the  importance  of  the  subject,  and 
the  interest  which  every  physician  should  take  in  arresting  the 
advance  of  these  sequelse  of  disease. 

It  is  in  view  of  these  effects  of  chronic  suppuration  of  the 
middle  ear,  that  English  life  insurance  companies  are  said  to 
decline  to  insure  the  lives  of  persons  that  are  affected  with  the 
disease.  A  little  consideration  will  show,  that  any  person  who 
has  a  hole  in  the  membrana  tympani,  and  an  ulcerative  pro- 
cess in  the  parts  beyond,  has  a  much  less  chance  for  long  life, 
than  one  whose  brain  and  vascular  circulation  are  not  thus 
exposed  to  the  ravages  of  disease.  Very  few  persons  com- 
paratively, who  suffer  from  chronic  suppuration,  live  out  their 
days,  while  many  of  them  die  very  young. 

On  page  237  of  this  volume,  these  consequences  are  tabu- 
lated.   It  is  now  proposed  to  enter  into  a  discussion  of  their 


388  AUEAL  POLYPI. 

nature  and  treatment.  At  the  risk  of  reiteration,  it  should  be 
again  said,  that  none  of  the  results  of  chronic  suppuration 
should  ever  be  regarded  as  independent  affections. 

—POLYPI. 

Celsus  and  Pliny  used  the  term  polypus  for  a  tumor  spring- 
ing from  any  cavity  of  the  body.  The  name  was  adopted 
under  the  old  system  of  nomenclature,  when  an  exact  know- 
ledge of  the  nature  and  structure  of  growths  or  parts  was  not 
regarded  in  giving  them  a  name.  It  is  an  unfortunate  one, 
for  there  is  scarcely  any  resemblance  between  the  many  footed 
aquatic  animal  after  which  morbid  growths  were  called,  and 
the  exuberant  granulations  or  tumors  which  arise  from  the 
cavity  of  the  tympanum  and  the  auditory  canal.  It  is  prob- 
ably too  late,  or  too  early,  to  effect  any  change  in  the  nomen- 
clature, and  we  must  be  content  with  the  name  aural  polypi 
for  all  the  growths  that  occur  in  the  ear,  except  for  those 
of  an  osseous  structure  or  a  cancerous  nature. 

The  best  classification  of  aural  polypi  seems  to  me,  to  be 
that  of  Steudener,*  who  divides  them  into  three  varieties : 

1.  Mucous  polypi. 

2.  Fibromata. 

3.  Myxomata. 

To  this  we  may  add  a  fourth  class : 

4.  Angioma  ;  a  case  of  which,  as  occurring  in  the  ear,  was 
first  reported  by  Dr.  A.  H.Buck.f 

Cases  of  epithelioma,  sarcoma,  and  cholesteatoma  have 
also  been  reported,  but  they  do  not  properly  belong  to 
the  subject  of  aural  polypi,  although  they  are  sometimes  con- 
founded with  the  single  growths,  and  perhaps  arise  from 
them.  For  the  sake  of  convenience,  their  consideration  will 
be  deferred  until  the  benignant  tumors  have  been  considered. 
Kessel  X  also  reports  a  peculiar  growth  which  is  called  a  clot 
of  blood  in  process  of  organization,  but  it  hardly  requires  a 
separate  classification. 

*  Archiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  203. 

t  Transactions  of  the  American  Otological  Society,  1870. 

%  Archiv  far  Ohrenheilkunde,  Bd.  IV.,  p.  187. 


AUEAL  POLYPI. 

The  mucous  polypi  are  altogether  the  most  frequent  of 
those  found  in  the  ear.  The  fibromata,  or  polypi  made  up  of 
denser  connective  tissue  than  the  mucous  growths,  are  next  in 
frequency.  Buck  thinks  that  about  one  in  ten  of  all  the 
polypi  that  have  been  microscopically  examined,  belong  to 
the  class  of  fibroma.  Myxoma  has  been  reported  by  Steu- 
dener  only,  so  far  as  I  have  been  able  to  find. 

Nature  of  Aural  Polypi. — In  an  article  published  in  1864,* 
I  attempted  to  show  on  clinical  grounds,  that  aural  polypi 
were  analogous  in  structure  to  exuberant  granulations,  occur- 
ring as  direct  results  of  an  ulcerative  process.  This  view  at 
once  clears  up  the  nature  of  these  growths  and  takes  away  the 
fictitious  importance  which  the  view  that  regards  them  as  inde- 
pendent tumors  caused  them  to  assume.  Professor  Theodore 
Billroth,  in  1855,  whose  monograph  I  had  not  then  seen,  exam- 
ined seven  polypi  which  were  found  in  the  external  auditory 
canal,  and  Kessel  f  quotes  him  as  stating  that  the  chief  con- 
tents of  those  polypi  were  granulation  material,  although  he 
states  that  the  existence  of  ciliated  epithelium  and  the  vascu- 
lar network  entitles  them  to  the  rank  of  independent  tumors. 
Billroth's  idea  as  to  the  nature  of  mucous  polypi  is  perhaps 
the  most  correct  and  the  simplest.  They  consist  of  a  delicate 
but  loose  stroma  of  connective  tissue.  In  the  meshes  of  this 
connective  tissue  are  round,  spindle-shaped  or  stellate  cells, 
and  they  are  covered  by  a  single  or  multiple  layer  of  epithe- 
lium cells. 

The  fibrous  polypi  consist  of  a  dense  connective  tissue, 
having  but  few  cellular  elements  in  its  fibres  and  covered  by 
pavement  epithelium. 

Angioma  is  made  up  of  newly  formed  vessels,  or  of  vessels 
in  whose  walls  are  newly  formed  elements.  It  is  quite  a  com- 
mon variety  of  tumor,  although  the  case  to  which  allusion  has 
already  been  made,  is  the  only  one  that  has  been  reported  as 
having  been  found  in  the  ear.  Virchow^:  named  the  form 
which  Dr.  Buck  examined,  angioma  cavernosum,  because  it  was 

*  American  Medical  Times,  August  6, 1864. 

\  Archiv  fur  Ohrenheilkunde,  1.  c. 

\  Die  krankhaften  Gescliwiilste  IV.,  Bd.  I.,  Hf.      .,  p.  307. 


390 


AURAL  POLYPI. 


characterized  by  the  existence  of  a  network  of  blood  spaces, 
occupying  the  place  and  doing  the  work  of  capillary  vessels. 

In  Dr.  Buck's  case  the  angioma  seems  to  have  been 
secondary  to  a  common  mucous  polypus,  which  was  removed 
a  few  days  before.  The  angioma  assumed  its  character  of  a 
vascular  growth  from  that  removal,  and  such  a  tumor  would 
probably  be  sometimes  found  were  microscopic  examinations 
made  of  the  growths  that  often  spring  up  after  the  removal  of 
simple  mucous  polypi. 

Dr.  H.  C.  Eno,  pathologist  to  the  Manhattan  Eye  and  Ear 
Hospital,  and  assistant-surgeon  to  the  New  York  Eye  and  Ear 
Infirmary,  examined  three  specimens  of  aural  polypi,  which  I 
removed  from  the  auditory  canal,  and  made  drawings  of  their 
structure.  These  drawings  will,  I  think,  better  illustrate  the 
nature  of  these  growths  than  further  remarks. 


Section  of  Aural  Polypus,  Case  I. 


A.  Layer  of  laminated  epithelium,  similar  to  that  of  skin.  B,  B.  Epithelial  cones,  the  com- 
mencement of  gland  formation.  C.  Loose  connective  tissue,  containing  round  and  spindle 
cells  and  some  fibres.    D.  Blood-vessels. 


Case  I. — Thomas  Gibney,  age  23.  March  14,  1871.  Brooklyn  Eye  and 
Ear  Hospital. 

History.  —Seven  days  ago  extensive  swelling  in  meauricular  region ;  gran- 
ulations springing  out  of  auditory  canal. 

Diagnosis. — Abscess  of  anterior  wall  of  auditory  canal,  with  polypoid 
growth  arising  from  same  point. 

Treatment. — Polypus  removed  and  abscess  opened ;  ordered  chloral  hydrate, 


AUEAL  POLYPI. 


391 


gr.  sv. ;  if  does  not  sleep  well  to-night,  to  come  at  12  M.  March  lGth — Con- 
tinue treatment.  March  18th — Touched  polypus  with  nitric  acid.  March  21st 
— Much  better,  touched  with  argent  nit.  mit. 

It  should  be  said  that  the  usual  point  of  origin  of  aural 
polypi,  is  the  cavity  of  the  tympanum.  They  may  arise  from 
the  auditory  canal,  but  if  so,  they  are  the  result  of  suppuration, 
that  has  been  prolonged,  or  that  has  been  augmented  by  the  use 
of  poultices,  and  which  have  rapidly  broken  down  the  integu- 
ment of  the  canal,  and  rendered  it  more  like  its  neighbor,  the 
mucous  membrane  of  the  tympanic  cavity.  Polypi  and  granula- 
tions often,  however,  have  their  seat  in  the  canal,  but  they  are 
usually  accompanied  by  the  same  growth  in  the  deeper  parts, 
when  the  whole  character  of  the  tissue  lining  the  canal  has 
been  changed  by  an  ulcerative  process,  extending  from  the 
tympanic  cavity.  As  will  be  seen  by  comparing  the  illustra- 
tions of  Case  I.,  which  arose  from  the  auditory  canal,  with 
those  that  sprang  from  the  cavity  of  the  tympanum,  the  only 
essential  difference  is  that  the  epithelium  is  thicker. 

Fig.  76. 


Section  of  Aural  Polypus,  Case  II. 

A.  Epithelium.    B.  Substance  of  polypus,  made  up  of  a  mass  of  round  cells  about  the  size  of 

white  blood  corpuscles.   C,  C.  Capillary  vessels,  containing  white  blood  corpuscles. 

Case  II. — Mary  Jane  N.,  set.  13.  January  10,  1872.  Manhattan  Eye  and 
Ear  Hospital.  Otitis  media  suppurativa,  with  polypus  in  right  ear.  Polypus 
nearly  fills  auditory  canal.  Discharge  from  both  ears  from  scarlet  fever  since  a 
child.  Large  perforations  in  membranae  tympani.  Polypus  removed  with 
snare. 


392 


AURAL  POLYPI. 
Fig.  77. 


Section  of  Aural  Polypi. 

A,  C,  and  D,  same  as  in  Fig.  75.    E.  Gland  lined  with  cylindrical  epithelium.    F.  Trans- 
verse section  of  the  same. 

Case  III. — Mary  Ann  McC,  age  14.  January  24,  1871.  Manhattan  Eye 
and  Ear  Hospital. 

History. — Discharge  from  right  ear  since  a  child.     Canse  unknown. 

Diagnosis. — Otitis  media  suppurativa,  with  polypus  of  right  ear. 

Hearing. — R.,  watch  heard  on  contact.     L.,  normal. 

Meatus. — R ,  full  of  pus. 

Treatment. — Syringed.  January  31st — Two  polypi  removed  with  snare. 
Douche  and  syringing.  Politzer,  warm  douche.  Nitric  acid  to  stumps.  Hear- 
ing distance  increased  to  2". 

Aural  polypi  are  more  rarely  found  by  the  physicians  of  to- 
day, than  by  our  predecessors,  for  the  simple  reason  that  aural 
diseases  are  more  carefully  observed,  and  they  have  no  such 
opportunities  to  occur,  as  were  enjoyed  when  a  discharge  of 
pus  from  the  ear  was  not  treated.  A  tumor  can  scarcely  arise 
from  a  tympanic  cavity  or  an  auditory  canal  that  is  kept  thor- 
oughly freed  from  the  pus  of  a  chronic  suppurative  process. 

MALIGNANT  GROWTHS. 

The  malignant  growths  that  have  as  yet  been  found  in  the 
ear,  and  which  may  be  mistaken  for  malignant  polypi,  are  epi- 
thelial carcinoma,  fibrous  and  medullary  carcinoma.     Gruber* 


*  Text-book,  p.  597. 


MALIGNANT  GEOWTHS.  393 

relates  a  case  where  an  epithelial  carcinoma  originated  in 
the  integument  in  the  region  of  the  mastoid  bone,  gradually 
destroyed  the  mastoid  process,  and  finally  reached  the  mucous 
membrane  of  the  middle  ear.  The  membrana  tympani  was 
destroyed  by  the  growth.  The  patient  heard  a  watch  when 
laid  upon  this  ear ;  he  had  no  tinnitus  aurium,  and  so  few 
symptoms  beyond  extremely  slight  lancinating  pain,  that  after 
the  tumor  had  existed  for  three  years  he  still  did  his  work 
as  a  day  laborer. 

Dr.  Kobertson  of  Albany,*  reports  a  case  of  supposed  poly- 
pus in  the  ear,  which  proved  to  be,  on  microscopic  examination, 
a  specimen  of  "  fasciculated  sarcoma  corresponding  to  plates 
of  tumors  constituted  by  embryonic  tissue,  found  in  the 
Manual  d'Histologie  Pathologique,  by  Cornil  and  Ranvier  of 
Paris."  An  attempt  to  remove  the  growth  by  cutting  off 
pieces  of  it,  caused  a  hemorrhage  of  fourteen  fluid  ounces  in 
a  few  moments.  The  hemorrhage  was  arrested  by  a  tampon 
of  cotton  dipped  in  a  solution  of  persulphate  of  iron. 

Cholesteatoma,  the  pearl  tumors  of  J.  Muller,  have  also 
been  found  in  the  cavity  of  the  tympanum  arising  from  an 
inflamed  or  ulcerated  mucous  membrane.  They  consist,  ac- 
cording to  Gruber,f  of  small  degenerated  epithelial  cells, 
between  which  lie  cholestearine  crystals  and  other  fatty  ma- 
terial. They  sometimes  destroy  the  bone  by  pressure,  and 
they  may  even  extend  into  the  cranial  cavity. 

Osteo-sarcoma  of  the  cavity  of  the  tympanum,  extending 
into  the  auditory  canal,  was  also  observed  by  Boke.J  The  pa- 
tient died  of  meningitis.  Wilde§  reports  an  interesting  case  of 
osteo-sarcoma.  A  boy  of  seven  years  of  age,  in  apparently  good 
health,  was  brought  to  Mr.  Wilde  on  account  of  a  discharge 
from  the  external  auditory  canal.  A  small  polypus  was  dis- 
covered. It  was  removed,  but  it  returned  quickly  on  the  third 
day.  It  was  again  and  repeatedly  removed,  but  it  recurred 
again  and  again,  and  subsequently  the  child  was  seized  with  an 
epileptic  fit.  A  fluctuating  point  was  then  found  upon  the  mas- 
toid process  ;  this  was  cut  down  upon  at  once,  and  the  opening 
gave  exit  to  a  large  amount  of  pus.    The  abscess  communicated 

*  Transactions  of  the  American  Otological  Society,  1870. 

f  Lehrbuch,  p.  597.  %  Gruber,  1.  c.  §  Test-book,  p.  208. 


394  MALIGNANT  GKOWTHS. 

by  a  fistula  with  the  external  auditory  canal.  A  fungous  growth 
soon  sprouted  up  through  the  incision.  Repeated  attacks  of 
epilepsy  occurred,  and  death  soon  ensued.  Upon  examination 
there  was  found  an  osteo-sarcoma  of  the  petrous  and  mastoid 
portions  of  the  temporal  bone.  Wilde,  thinks  that  the  original 
disease  was  in  the  bone,  and  that  the  aural  discharge  and 
fungous  were  but  secondary  appearances.  The  history  is  not 
detailed  enough  to  allow  us  to  state  with  any  positiveness  the 
first  cause  of  the  affection,  but  it  may  have  been  an  ulcer  in 
the  tympanic  cavity,  which  secondarily  involved  the  bone. 

These  malignant  tumors  of  the  ear  should  be  carefully  dis- 
tinguished from  the  benign  mucous  and  fibrous  polypi  that  are 
the  frequent  results  of  a  neglected  suppuration.  Yet  it  should 
be  remembered  that  the  malignant  growths  may  be  also  the 
result  of  the  same  original  process.  This  fact  adds  to  the 
importance  of  the  subject.  Perhaps  some  of  the  cases  of 
death  from  the  removal  of  aural  polypi,  should  be  referred  to 
the  extension  of  the  malignant  disease,  rather  than  to  the 
excision  of  a  tumor  from  the  ear. 

Treatment. — The  treatment  of  an  aural  polypus  should 
begin  with  the  removal  of  the  growth.  I  have  said  begin  with 
deliberation,  because  it  is  a  mistake  to  suppose  that  the 
removal  of  the  polypus  will  be  any  more  than  the  beginning 
of  the  treatment  of  the  disease  of  which  the  polypus  is  a 
symptom.  Besides,  aural  polypi  often  spring  up  very  rapidly, 
even  after  they  have  been  thoroughly  removed,  and  when  they 
are  simple  growths ;  moreover,  we  are  often  obliged  to  remove 
them  several  times  from  the  ear,  especially  where  we  cannot 
have  full  control  of  our  patients  and  cause  them  to  attend  to 
the  after-treatment. 

Wilde's  snare,  as  modified  by  Blake,  will  be  found  the  best 
instrument  for  the  removal  of  well-defined  polypi  with  a  pedi- 
cle. In  Wilde's  snare,  the  bar  which  carries  the  slide,  and  the 
arm  which  supports  the  wire  used  in  cutting  off  the  polypus, 
are  in  one  piece.  Dr.  Blake  has  substituted  a  movable  tube 
of  German  silver  (d)  for  the  fixed  arm.  "  This  tube  expands 
at  the  outer  ends  into  a  flattened  head  (/),  having  two  open- 
ings for  the  passage  of  the  wire ;  the  inner  end  of  the  tube  fits 


AURAL  POLYPI — TREATMENT. 


395 


into  a  broad  band  on  the  slide-bar  (b).  The  ends  of  the  wire 
passing  down  the  tube  are  fastened  to  a  pin  on  the  upper  part 
of  the  slide  (c),  below  which  is  a  ring,  by  which  traction  can 
be  made."  The  instrument  is  better  than  Wilde's,  because  it 
can  be  turned  in  any  direction  without  injuring  the  walls  of 
the  canal.  A  paracentesis  needle  may  also  be  used  in  the  han- 
dle, but  it  should  be  rather  longer  than  the  one  in  the  cut. 


Fig.  78. 


Blake's  Modification  of  Wilde's  Snare,  with  Paracentesis  Needle. 

Scissors  may  sometimes  be  used  with  advantage  to  remove 
aural  polypi.  I  have  found  those  that  are  here  represented 
very  convenient,  especially  for  the  removal  of  growths  from 
the  walls  of  the  auditory  canal. 

Fig.  79. 


Scissors  for  the  Removal  of  Aural  Polypi. 

Forceps  may  sometimes  be  employed,  although  I  prefer  the 
snare  and  scissors  to  all  other  mechanical  means  for  removing 
polypi  or  granulations.  Forceps,  unless  used  with  great  gen- 
tleness and  care,  may  wrench  more  than  the  morbid  growth 
from  the  cavity  of  the  tympanum,  and  thus  do  great  harm. 

Yery  small  pedunculated  growths,  such  as  was  found 
in  the  case  recorded  on  page  385,  may  be  often  removed  by 
the  simple  angular-toothed  forceps,  figured  on  page   80   of 


396  AUEAL  POLYPI — TREATMENT. 

this  work.  .  True  exuberant  granulations,  having  no  pedicle, 
but  arising  from  a  broad  surface,  usually  resist  treatment  with 
great  obstinacy,  because  they  are  difficult  to  reach  and  entirely 
remove  with  instruments,  and  because  they  usually  cover 
carious  or  necrosed  bone.  Caustics  are  perhaps  the  only 
means  of  removing  such  growths.  The  agents  I  usually  em- 
ploy for  such  cases  are  strong  solutions  of  nitrate  of  silver — 
from  40  to  480  grains  to  the  ounce — and  fuming*nitric  acid. 
The  nitrate  of  silver  may  be  poured  in  upon  the  part,  and 
then  neutralized  by  the  subsequent  instillation  of  a  solution 
of  common  salt. 


Fig, 


Binton's  Forceps. 

Dr.  O.  D.  Pomeroy*  reports  a  case  of  "  the  removal  of  a 
polypoid  granulation  of  ten  years  standing,  by  four  applica- 
tions of  a  forty-grain  solution  of  nitrate  of  silver."  A  pipette 
was  used  to  drop  the  nitrate  of  silver  upon  the  growth. 
Although  it  is  evident  from  the  history,  that  the  disease  which 
allowed  the  formation  of  the  polypus — a  chronic  suppuration 
from  scarlet  fever — had  existed  for  ten  years,  it  does  not  cer- 
tainly appear  that  the  polypus  had  been  in  the  ear  so  long. 
The  polypus  is  said  to  have  sprung  from  the  membrana  tym- 
pani,  which  was  perforate,  however. 

I  am  in  the  habit  of  treating  granulations  that  arise  from 
the  cavity  of  the  tympanum,  where  it  is  somewhat  dangerous 
to  use  forceps,  scissors,  or  snare,  by  numerous  punctures  with 
a  cataract  needle.  The  puncturing  causes  considerable  hem- 
orrhage.    After  the  blood  is  wiped  away,  a  caustic  should  be 

*  Medical  Record,  vol.  vi.     Reported  by  D.  Webster,  M.D. 


AUEAL  POLYPI — TREATMENT.  397 

applied.  Nitric  or  chromic  acid  may  be  thus  used,  by  means 
of  a  glass  rod,  a  cotton-holder  armed  with  cotton,  or  a  bit  of 
wood. 

The  pain  from  these  applications  is  usually  so  little,  that 
even  children  will  bear  them  without  shrinking.  The  granu- 
lations are  of  such  a  low  grade  of  organization  that  they  have 
very  little  sensitiveness.  There  are,  of  course,  many  other 
agents  than  those  that  have  been  mentioned,  which  may  be 
profitably  used  in  cauterizing  the  bases  of  polypi  that  have 
been  removed  by  instruments,  and  in  destroying  fungous 
granulations.  Chromic  acid  is  very  much  employed,  as  well 
as  the  acid  nitrate  of  mercury. 

Fig.  81. 


Angular  Glass  Mod  for  applying  Acids  to  the  Cavity  of  the  Tympanum. 

Dr  Edward  H.  Clarke  often  injects  a  solution  of  the  per- 
chloride  or  persulphate  of  iron  into  the  interior  of  a  polypus, 
and  with  the  happiest  results.*  Two  or  three  drops  of  the 
liquor  ferri  perchloridi,  of  the  liquor  ferri  persulphatis,  are 
injected  into  the  growth  by  means  of  a  hypodermic  syringe. 

The  galvano-cautery  is  said  to  be  an  efficient  and  painless 
method  of  removing  granulations  from  the  cavity  of  the  tym- 
panum. Dr.  Blake  does  not  consider  it  a  painless  method  of 
perforating  the  drum-head  however,  he  having  witnessed  its 
operation,  in  Vienna,  in  some  experiments  made  by  Politzer, 
Chemani,  and  Moos.  Allusion  has  already  been  made,  on  page 
331,  to  this  means  of  puncturing  the  membrana  tympani.  In 
each  of  the  cases  observed  by  Blake,  where  an  attempt  was 
made  to  perforate  the  membrana  tympani  with  a  galvano-cau- 
tery, the  pain  was  so  severe  that  further  attempts  were  aban- 

*  On  Polypus  of  the  Ear,  p.  61. 


398  AUKAL  POLYPI. 

doned.  It  is  probable,  however,  that  it  is  not  so  painful  a  process 
when  used  to  remove  granulations.  Schwartze  *  speaks  very 
highly  of  the  galvano-cautery  for  the  purpose  of  removing  mor- 
bid growths.  Although  the  pain  is  considerable,  much  more 
severe  than  from  the  use  of  the  pure  nitrate  of  silver,  the  reaction 
is  slight.  Schwartze  also  believes  that  the  galvano-cautery  is 
a  more  efficient  means  of  removing  the  growth  than  the  ordi- 
nary caustics. 

No  matter  which  of  the  methods  that  have  been  detailed 
be  employed  in  removing  an  aural  polypus,  the  subsequent 
treatment  will  be  the  same.  The  case,  after  the  removal  of 
the  growth — if  caries,  necrosis,  or  exostosis  do  not  exist — 
is  one  of  simple  chronic  suppuration,  that  should  be  managed 
in  the  manner  that  has  been  set  forth  in  the  preceding  chapter. 
The  removal  of  the  polypus  may  improve  the  hearing  very 
much,  or  it  may  scarcely  benefit  it.  If  the  polypus  were  a 
mere  mechanical  obstruction  to  the  entrance  of  sound,  its 
removal  would  of  course  at  once  restore  the  hearing  power ; 
but,  as  has  been  seen,  it  is  much  more  than  that.  The  prog- 
nosis in  regard  to  the  hearing  power  in  cases  of  aural  polypi 
should  always  be  guarded.  The  hemorrhage  from  their  re- 
moval is  usually  trifling.  If  it  be  excessive,  as  in  Dr.  Robert- 
son's case  of  carcinoma,  a  tampon  saturated  in  sulphate  of 
iron  will  arrest  it.  I  usually  employ  Rohland's  styptic  cotton 
for  the  arrest  of  hemorrhage  from  the  base  of  a  polypus,  if  the 
use  of  cotton-wool  do  not  check  it  at  once. 

BLAKE'S  MIDDLE  EAR  MIRROR. 

Dr.  Blake  has  invented  a  middle  ear  mirror,  for  the  pur- 
pose of  examining  cases  of  suppurative  inflammation  of  the 
middle  ear  more  accurately,  than  can  be  done  with  the  aural 
speculum.f  It  is  said  to  be  especially  useful  in  detecting  the 
exact  site  of  small  granulations.  The  use  of  Dr.  Blake's 
instrument,  as  he  himself  states,  "  is  of  necessity  limited  to  a 
very  small  number  of  cases,  as  both  a  moderately  wide  meatus 
and  a  comparatively  large  opening  in  the  membrana  tympani 

*  Archiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  8. 

t  Transactions  of  the  American  Otological  Society,  1872,  p.  83. 


MIDDLE   EAE  MIBEOE. 


399 


must  exist,  to  permit  of  the  introduction  of  a  mirror  of  suffi- 
cient size."  The  instrument  was  first  constructed  to  accurately 
determine  the  origin  of  a  growth  which  was  external  to  the 
membrana  tympani,  but  which  was  hidden  from  view  by  the 
conformation  of  the  external  auditory  canal. 

The  mirror  is  attached  to  Weber's  tenotome,  the  cutting- 
hook  being  replaced  by  a  polished  steel  mirror  of  from  one- 
sixteenth  to  one-eighth  of  an  inch  in  diameter.  In  some  cases 
Dr.  Blake  thinks  a  larger  mirror  may  be  used.  "  The  mirror 
is  made  by  flattening  out  the  end  of  the  shaft,  bending  it 
at  the  proper  angle,  tempering  and  polishing  it.  The  shaft  is 
ductile,  so  that  the  angle  of  the  mirror  can  be  varied  at  will. 
Shafts  of  various  lengths,  with  mirrors  of  various  sizes,  may 
be  rotated  by  movement  of  the  stud  in  the  handle."  * 

Fig.  82. 


Blake's  Middle  Ear  Mirror. 

For  the  benefit  of  the  student  and  young  practitioner,  we 
may  formulate  our  knowledge  of  aural  polypi  as  follows  : 

I. — True  aural  polypi  are  morbid  growths  analogous  to 
exuberant  granulations. 

*  Messrs.  Otto  &  Keynolds,  of  fhis  city,  have  greatly  improved  Weber's 
tenotome  and  Blake's  middle  ear  mirror,  by  placing  the  tenotome  and  mirror 
in  a  slit  canula,  so  that  no  unscrewing  is  needed  to  remove  them. 


400  EXOSTOSES. 

II. — They  are  the  result  of  a  long-continued,  or  recent  and 
violent  purulent  inflammation  of  the  cavity  of  the  tympanum 
or  external  auditory  canal — usually  of  the  former. 

III. — Their  removal  is  but  the  beginning  of  a  treatment  of 
the  disease  of  which  they  are  consequences  and  symptoms. 

TV. — The  hearing  power  of  the  patient  will  not  be  restored, 
although  usually  improved  by  the  removal  of  an  aural  polypus. 

Y. — Malignant  growths  occur  in  the  ear,  which  assume  the 
form  of,  and  may  be  mistaken  for,  simple  polypi. 


EXOSTOSES. 

Exostoses,  hyperostoses  or  bony  growths  sometimes  occur 
in  the  osseous  portion  of  the  auditory  canal  and  in  the  cavity 
of  the  tympanum.  They  may  be  divided  into  two  great  classes 
— the  congenital  and  acquired  forms.  With  the  congenital  we 
have  very  little  to  do.  Inasmuch  as  they  are  not  consequences 
of  chronic  suppuration,  they  do  not  usually,  if  ever,  become  a 
source  of  trouble,  and  are  generally  seen  incidentally — that  is, 
when  a  patient's  ear  is  being  examined  for  some  disease  inde- 
pendent of  the  exostosis.  In  these  congenital  cases  the  whole 
caliber  of  the  canal  is  sometimes  invaded  by  a  general  thick- 
ening of  the  bone,  but  more  frequently  the  growths  extend 
from  one  point  with  a  pretty  well  defined  pedicle. 

Professor  S.  Moos*  believes  that  osseous  tumors  in  the  ex- 
ternal auditory  canal  are  relatively  frequent,  and  he  has  ob- 
served three  cases  of  the  symmetrical  formation  of  exostoses 
in  both  auditory  canals,  in  persons  who  consulted  him  for  a 
catarrh  of  the  middle  ear.  "  The  tumors  developed  invariably 
from  the  upper  wall  of  the  external  auditory  canal,  close  to 
the  drum-head,  and  opposite  Shrapnell's  membrane."  None 
of  the  patients  had  ever  suffered  from  gout,  rheumatism, 
syphilis,  or  a  suppuration  in  the  ear.  Moos  thinks  that  these 
cases  were  consequent  upon  irritative  processes  occurring  at 
the  time  when  the  annulus  tympanicus  unites  with  the  squa- 
mous portion  of  the  temporal  bone.     Dr.  Gruening  reported 

*  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  p.  136. 


CONGENITAL  EXOSTOSES.  401 

two  similar  cases  at  a  meeting  of  the  New  York  Oph.th.almo- 
logical  Society,  in  April,  1872. 

These  congenital  bony  growths  do  not  require  treatment, 
and  should  not  be  interfered  with. 

When  the  subject  is  old,  and  the  auditory  canal  is  naturally 
narrowed  by  the  alteration  in  position  in  the  lower  jaw,  some 
trouble  may  be  experienced  from  the  impaction  of  wax  in  the 
ear  in  cases  of  congenital  exostoses,  inasmuch  as  the  usual 
means  of  its  removal — the  motions  of  the  jaw — cannot  produce 
the  same  effect  upon  the  narrow  passage. 

Bonnafont*  reports  an  interesting  case  of  an  aural  exosto- 
sis, which,  so  far  as  I  can  judge  from  the  history,  which  is  not 
very  detailed  nor  exact,  seems  to  have  been  congenital,  and  to 
have  continued  to  grow  after  birth.  It  completely  obliterated 
the  auditory  canal :  "  Observation  oVun  cas  de  surdite  complete 
de  Voreille  gauche  due  a  V obliteration  de  conduit  auditif  -par  une 
tumeur  osseuse,  siegeant  pres  la  membrane  du  tympan,  guerie  par 
le  trepanation  de  la  tumeur"  There  was  no  history  of  previous 
pain  or  suppuration.  By  the  use  of  a  point  of  nitrate  of  sil- 
ver, for  six  sittings,  the  bone  was  exposed  at  the  centre  of  the 
growth,  and  it  was  then  removed  by  boring  into  it  with  a  rat- 
tailed  file.  In  ten  applications  of  this  file,  which  were  not 
very  painful,  an  opening  was  made.  A  whalebone  probe  was 
then  fastened  in  the  opening.  This  opening  was  kept  up  for 
some  months,  and  after  it  was  made  the  tick  of  the  watch  was 
heard  for  some  inches.  Some  years  after,  the  opening  through 
the  exostosis  still  remained. 

Professor  H.  Welcker,  f  of  Halle,  in  an  article  upon  bony  growths  in  the  ear, 
found  upon  the  dead  subject,  gives  some  interesting  facts  in  regard  to  these 
formations.  Welcker  quotes  from  Seligman,  who  found  exostoses  very  fre- 
quently in  the  external  auditory  canals  of  the  skulls  of  American  Indians,  that 
had  been  misshapen  by  pressure  exerted  upon  them  in  infancy.  "  Of  six  such 
skulls,  five  were  found  to  have  this  kind  of  exostoses."  Seligman  was  inclined 
to  believe  that  these  growths  were  a  peculiarity  of  race ;  but  Welcker  does  not 
agree  with  him,  because  he  found  them  in  other  Indians  not  of  the  tribe 
whose  skulls  were  examined  by  Professor  Seligman,  and  whose  bones  had  not 
been  changed  by  pressure.    Welcker  also  adds  that  these  exostoses  are  not 

*  Monatsschrift  fur  Ohrenheilkunde,  JahrganglL,  No.  8.  Lue  aTAcademie 
Imperiale  de  Medecine,  26th  May,  1 868. 

\  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  171. 
2fi 


402  INFLAMMATORY  EXOSTOSES. 

extremely  rare  among  the  cultured  population  of  Europe,  and  as  shown  by 
the  test-books  and  0.  0.  Weber's  collection,  the  external  auditory  canal  is  a 
favorite  position  for  them.  Welcker  thinks  that  Seligman's  observations  show 
that  exostoses  of  the  external  auditory  canal  are  more  frequent  among  the 
Indian  tribes  than  among  the  people  of  Europe,  although  he  does  not  think 
there  is  any  race  peculiarity  in  them.  The  exostoses  found  by  Seligman,  in 
such  relative  frequency  among  North  American  Indians,  seem  to  plainly  belong 
to  the  class  of  congenital  growths  which  have  been  reported  by  Moos,  Gruen- 
ing,  and  Agnew ;  but  I  have  no  doubt  that  their  origin  was,  as  Moos  states, 
due  to  some  local  irritation,  which  caused  a  proliferation  of  bone. 


INFLAMMATORY   OR  ACQUIRED  EXOSTOSES. 

The  cases  of  acquired  exostoses  are  a  much  more  serious 
matter  than  the  congenital  affections  of  the  same  kind.  They 
arise  in  the  course  of  a  chronic  suppuration  of  the  middle  ear ; 
they  usually  grow  with  more  or  less  rapidity,  and  they  may 
finally  block  up  the  tympanic  cavity  and  cause  retention  of 
pus  with  all  its  fatal  results.  Such  a  case  will  be  found  at  the 
close  of  this  section.  They  are  the  results  of  a  local  irritation, 
which  has  caused  in  the  first  place  a  periostitis,  and  seconda- 
rily an  enlargement  of  bone.  This  local  irritation  may  be 
either  the  constant  presence  of  pus  on  the  walls  of  the  canal, 
or  the  extension  of  the  inflammation  of  the  lining  membrane 
of  the  cavity  of  the  tympanum,  a  membrane  which  is  essen- 
tially a  periosteum,  to  the  true  periosteum  of  the  osseous  canal. 

Toynbee  was  inclined  to  ascribe  great  importance  to  the 
existence  of  a  rheumatic,  gouty,  or  syphilitic  diathesis  in  these 
cases  of  acquired  and  growing  exostoses.  In  his  work  upon  the 
ear,  he  details  nine  cases  of  bony  growths  in  the  external  audi- 
tory canal,  which  he  evidently  regards  as  an  independent  dis- 
ease, and  he  remarks  that  "  they  seem  to  be  the  result  of  a  rheu- 
matic or  gouty  diathesis."  The  author  published  four  cases,* 
in  which  there  was  no  such  diathesis,  but  in  which  the  growths 
were  general  enlargements  of  the  periosteum,  and  of  the  bone 
structure  beneath.  They  were  morbid  growths  consequent 
upon  lo6al  irritation.  A  more  complete  experience  has  sub- 
stantiated this  view.  Besides,  a  careful  examination  of  the 
history  of  Mr.  Toynbee's  cases  causes  the  doubt  to  be  raised 

*  New  York  Medical  Journal,  vol.  ii.,  p.  424. 


INFLAMMATORY  EXOSTOSES.  403 

whether  a  diathesis  had  much  to  do  with  the  formation  of 
several  of  them;  while  some  of  the  others  probably  belonged 
to  the  congenital  form.  In  Case  III.,  reported  by  Toynbee,  a 
discharge  had  existed  from  the  ear  for  eleven  years.  There 
was  a  perforation  of  the  membrana  tympani.  In  Case  VI. 
there  was  also  a  discharge.  In  Case  VII.  the  exostosis  was 
found  to  be  the  base  of  a  polypus.  In  Case  IX.  there  had  been 
a  discharge  from  the  ear  when  the  patient  was  a  boy.  Nine 
cases  are  reported  in  all ;  but  the  histories  are  not  very  fully 
given. 

Virchow*  says  that  local  influences  are  in  very  many  cases 
the  exciting  cause.  "  Some  have,  indeed,  educed  the  fre- 
quent cases  where  certain  constitutional  diseases,  especially 
rheumatism,  arthritis,  syphilis,  scorbutus,  rachitis,  have  pro- 
duced bony  tumors,  as  being  something  opposed  to  these 
local  causes.  Undoubtedly  the  field  of  these  conditions  was 
formerly  too  amplified,  and  we  may  say  that  scorbutus  is  now 
almost  entirely  excluded  from  the  list  of  causes,  and  that  the 
gouty  enlargements  of  bone  are  no  growths,  but  only  deposits  ; 
but  we  cannot  deny  the  influence  of  the  other  so-called  dys- 
crasia,  especially  of  the  rheumatic,  syphilitic,  and  rachitic 
diatheses.  In  spite  of  this,  their  influence  should  not  be  over- 
estimated." 

Polypi  are  frequently  found  upon  the  exostoses  that  arise 
in  the  course  of  a  suppuration  in  the  ear.  This  is,  of  course, 
proof  that  the  tissue  beneath  is  one  that  has  been  recently 
the  seat  of  inflammation. 

Dr.  Agnewf  has  seen  quite  a  number  of  cases  of  exostoses 
arising  in  cases  in  which  the  membrana  tympani  was  sound, 
and  which  he  believes  were  due  to  local  irritation  after  birth, 
such  as  the  use  of  instruments  for  the  purpose  of  cleansing  or 
scratching  the  canal,  the  formation  of  furuncles  in  the  same 
part,  and  so  forth. 

The  cases  of  acquired  exostosis  that  I  have  seen,  with  one 
exception,  arose  in  connection  with  suppuration  in  the  middle 
ear.    In  that  one  exception,  the  exostosis  was  so  large  that 

*  Die  Krankkaften  Gescnwiilste  II.,  Bd.  I.,  Halfte,  p.  73,  et  seq.  passim, 
f  Verbal  communication,  New  York  Opntkalniological  Society. 


404  EXOSTOSES — CASES. 

the  condition  of  the  membrana  tynipani  could  not  be  posi- 
tively known,  and,  unfortunately,  I  saw  the  case  but  once. 

Treatment. — The  treatment  of  these  growths  should  reach 
the  starting  point — the  middle  ear.  We  should  endeavor  to 
cause  the  suppuration  in  this  part  to  cease.  If  this  is  impossi- 
ble, as  it  may  be  in  the  chronic  cases  in  which  exostoses  occur, 
the  parts  should  be  kept  scrupulously  free  from  pus,  so  that  no 
blocking  up  of  the  morbid  material  may  occur.  The  patient 
should  be  taught  to  use  a  cotton-holder  and  the  warm  douche 
with  which  to  cleanse  the  canal,  and  Politzer's  method,  to  force 
the  purulent  material  into  the  tympanic  cavity.  Iodine  may 
be  painted  on  the  growths  with,  I  think,  some  benefit,  and  if 
a  diathesis  play  a  marked  part  in  causing  their  enlargement, 
the  appropriate  constitutional  treatment  should  be  given.  If 
the  exostoses  grow  to  such  an  extent  as  to  occlude  the  canal, 
Bonnafont's  operation  should  be  performed,  and  a  space  made 
through  the  growth  for  the  exit  of  pus. 

CASES. 

The  following  cases  will  give  a  fair  idea  of  the  appearance 
of  the  exostoses  that  are  consequences  of  chronic  suppuration. 
Some  of  them  have  been  previously  published  ;*  but  inasmuch 
as  the  subject  is  an  interesting  one,  and  the  book  in  which 
they  appeared  is  now  out  of  print,  they  may  perhaps  be  repro- 
duced with  propriety. 

Case  I. — Mr.  C,  set.  39,  was  seen  in  April,  1864,  in  consultation  with  Dr. 
C.  E.  Agnew,  under  whose  care  he  had  been  for  some  time.  He  had  lost, 
before  coming  under  observation,  tbe  hearing  of  his  right  ear  by  inflammation 
and  caries  of  the  middle  and  internal  ear.  Previous  to  the  above  date,  Dr.  A. 
had  removed  a  sequestrum  consisting  of  the  cochlea  and  semicircular  canals 
from  the  depths  of  the  external  auditory  canal  of  the  ear,  and  thus  terminated 
the  inflammatory  action.  In  early  life,  Mr.  C.  had  also  suffered  from  "  inflam* 
mation  "  of  the  left  ear,  producing  the  bony  growths  in  the  external  auditory 
canal,  which  render  his  case  the  subject  of  present  description.  He  now  hears 
with  his  ear  a  watch  tick  at  a  distance  of  five  inches.  In  the  auditory  canal, 
near  the  meatus,  are  two  bony  enlargements,  which  rise  from  the  anterior  and 
posterior  walls,  and  project  in  a  conical  form,  so  as  to  occupy  at  least  three- 

*  Von  Troltsch  on  the  Ear,  second  American  edition,  p.  131.. 


EXOSTOSES — CASES.  405 

fifths  of  its  caliber.  These  tumors  have  all  the  physical  appearance  of  exos- 
toses, and  seem  to  have  originated  in  periosteal  inflammation.  They  have 
been  steadily  treated  for  many  weeks  by  the  local  application  of  the  saturated 
tiucture  of  iodiue,  and  certainly  not  diminished  in  size.  Pressure  upon  them 
excites  pain  and  induces  an  increase  of  swelling  in  the  skin  which  covers 
them,  and  thus  temporarily  adds  to  the  deafness.  The  entire  absence  of  hear- 
ing in  the  fellow  ear,  and  the  failure  of  simple  means  to  render  the  exostoses 
smaller,  have  suggested  the  propriety  of  some  surgical  operation  for  their 
removal.  Such  a  proceeding  has  been  thus  far  postponed  by  the  occurrence 
of  an  acute  attack  of  inflammation  in  the  parts  extending  to  the  tympanum, 
with  symptoms  of  more  than  usual  cerebral  irritation.  From  this  disagreeable 
complication  he  has  entirely  recovered  under  Dr.  Agnew's  care. 

His  general  health  being  impaired,  he  went  abroad,  and  while  in  London 
consulted  Mr.  Toynbee,  who  used  bougies,  hoping  to  dilate  the  canal ;  but, 
according  to  Mr.  C.'s  statements,  they  caused  much  pain  and  accomplished 
nothing.  Through  Dr.  Agnew's  courtesy,  I  again  saw  the  patient  in  the 
spring  of  1865,  and  found  that  the  growths  had  so  much  increased  that  only  a 
small  probe  could  be  passed  between  them,  and  the  hearing  more  impaired. 
The  patient  could  still,  however,  hear  the  watch  tick,  but  only  when  laid  on 
the  auricle. 

The  patient  whose  case  is  here  given,  died  about  two  years 
after,  of  inflammation  of  the  membranes  of  the  brain,  induced 
by  suppuration  in  the  cavity  of  the  tympanum,  the  pus  not 
being  able  to  find  an  outlet  on  account  of  the  presence  of 
exostoses.  Dr.  Agnew  exhibited  the  brain  and  temporal  bones 
before  the  New  York  Pathological  Society.  The  history  of 
the  other  ear  of  this  unfortunate  patient  will  be  found  in 
the  section  on  caries  and  necrosis. 

Case  II. — A  gentleman,  set.  40,  whom  I  saw  but  once,  in  June,  1864.  He 
states  that  he  had  a  "  running  "  from  his  right  ear  for  a  number  of  years.  For 
some  two  or  three  years  past  he  had  observed  that  the  ear  was  stopped  up. 
He  was  accustomed  to  remove  the  accumulating  discharge  by  thrusting  in  a 
match  armed  with  cotton.  There  is  seen  a  bony  growth  arising  from  the 
posterior  wall  of  the  meatus,  and  involving  the  whole  caliber  of  the  canal, 
except  a  space  large  enough  to  admit  an  ordinary  sized  silver  probe.  Through 
this  opening  a  slight  amount  of  purulent  discharge,  constantly  makes  its  way. 
There  was  gome  hypersemia  of  the  pharynx,  and  there  was  a  small  ulcer 
on  one  of  the  tonsils.  The  patient  was  in  excellent  general  health,  was  rather 
a  free  liver,  and  said  he  had  constitutional  syphihs  ;  but  no  good  evidence  of 
its  existence  now  existed.     The  patient  had  never  had  rheumatism  or  gout. 

Case  III. — Mr.  S. ,  set.  25,  Conn.  February  6,  1865  (a  patient  sent  to  me  by 
Dr.  Alfred  North,  of  Waterbury,  Ct.). — When  the  patient  was  three  or  four  years 
of  age  he  had  scarlet  fever,  at  which  time  his  ears  began  to  discharge,  and  they 


406  EXOSTOSES — CASES. 

have  continued  to  do  so  at  intervals  ever  since,  with  attacks  of  pain  in  the  ears, 
which  sometimes  lasted  for  weeks,  and  prevented  him  from  any  occupation  for 
the  time.  Eight  years  ago  his  ears  were  examined  and  polypi  discovered,  one 
of  which  was  removed  by  caustics.  The  attacks  of  pain  have  continued  to 
occur,  the  discharge  continues,  and  his  hearing  is  become  more  and  more  im- 
paired. He  is  just  now  suffering  from  acute  pain  referred  to  the  left  ear.  He 
hears  the  watch  about  one  inch  from  each  ear. 

In  the  right  meatus  there  is  seen  a  bony  growth  reaching  nearly  out  of  the 
orifice  of  the  external  meatus,  and  arising  from  the  posterior  wall.  The  space 
between  the  growth  and  the  anterior  and  upper  wall  is  about  large  enough  to 
admit  of  the  introduction  of  a  camel's  hair  brush.  In  the  left  meatus,  there  is 
seen  a  gelatinous  granulation,  also  reaching  nearly  out  to  the  orifice  of  the 
meatus. 

On  blowing  air  into  the  cavity  of  the  tympanum,  by  means  of  the  Eusta- 
chian catheter,  air  and  fluid  are  heard  making  their  exit  into  the  external 
meatus  ;  but  the  blocking  up  of  this  passage  prevents  their  emergence.  On 
the  right  side  pus  may  be  seen  in  the  orifice  between  the  bony  growth  and 
the  wall  of  the  meatus. 

The  confinement  of  the  fluid  in  the  middle  ear  accounts  for  the  pain  in  the 
left  side,  and  the  indication  of  treatment  was  to  secure  its  free  exit.  This  was 
clone  by  removing  the  gelatinous  growth  by  torsion,  the  patient  being  ether- 
ized, and  rendering  the  Eustachian  tubes  permeable  by  the  use  of  the  well- 
known  means — the  catheter  and  Politzer's  method.  The  granulation  was 
found  to  have  its  origin  from  a  general  bony  expansion  of  the  meatus.  This 
growth  had  no  one  growth  of  attachment,  but  involved  all  the  sides  of  the 
meatus,  somewhat  more  expanded  externally,  giving  the  bony  canal  rather  a 
funnel-shaped  appearance.  The  bone  was  roughened.  The  pain  in  the  ear 
disappeared  as  soon  as  these  means  for  securing  an  outlet  to  the  pus,  con- 
stantly secreted  from  the  cavity  of  the  tympanum,  and  passing  through  the 
perforated  membrana  tympani,  had  been  taken,  and  the  hearing  was  so  much 
improved  that  the  watch  was  heard  about  four  inches  from  the  left  auricle. 
He  remained  under  treatment  for  a  few  days,  and  then  returned  to  Waterbury, 
and  has  been  under  the  careful  and  able  observation  of  Dr.  North,  who  has 
applied  remedies  of  various  kinds  to  the  left  meatus,  the  patient  keeping  the 
Eustachian  tubes  permeable  by  means  of  gargles  and  Politzer's  apparatus. 
The  last  time  I  saw  the  patient  was  in  October  of  this  year  (1865),  when  the 
following  note  was  made  :  "  He  had  had  no  attack  of  pain  in  the  ear  since  the 
first  date.  There  is  still  a  considerable  discharge  of  pus  from  each  ear.  He 
hears  ordinary  conversation  well,  and  the  watch  ten  inches  from  his  left  ear, 
and  two  inches  on  the  right :  a  gain  of  one  inch  and  nine  inches  respectively." 
The  bony  growth  on  the  right  side  has  not  increased  any,  and  that  on  the  left 
is  now  smooth,  and  has  a  somewhat  glistening  appearance.  June,  1868 — Pa- 
tient still  remains  free  from  any  disturbing  symptoms. 

Dr.  North  writes  me,  March  25,  1873,  that  "  the  patient's  general  health  is 
good.  He  hears  ordinary  conversation  readily,  and  Dr.  North's  watch  8£ 
inches  from  the  left  auricle  and  \\  from  the  right.  The  bony  growth  has  a 
smooth,  shiny  appearance,  and  only  admits  the  passage  of  an  ordinary  sized 
probe.    The  discharge  from  the  ear  is  slight  and  of  a  watery  nature.    He  has 


EXOSTOSES — CASES.  407 

no  pain  in  either  ear.  Any  increase  of  the  impairment  of  hearing  is  always 
relieved  by  an  application  of  tincture  of  iodine  to  the  bony  growths." 

Case  IV. — Woman,  set.  27,  at  the  New  York  Eye  and  Ear  Infirmary.  No 
reliable  history  could  be  obtained  from  the  patient  as  to  her  ears,  except  that 
she  had  been  occasionally  hard  of  hearing  for  some  years.  She  was  quite  sure 
that  she  never  had  had  a  discharge  from  the  ears ;  was  in  good  general  health, 
and  had  always  been  so.  She  could  hear  the  watch  two  feet  from  the  left 
auricle,  and  twelve  inches  from  the  right.  The  left  membrana  tympani 
showed  evidences  of  previous  inflammatory  action,  there  being  thickening  of 
its  mucous  and  fibrous  layers.  There  is  a  bony  enlargement  of  the  posterior 
wall  of  the  right  meatus,  so  large  as  to  prevent  any  view  of  the  membrana 
tympani.  The  patient  was  seen  but  a  few  times,  not  continuing  under  treat- 
ment. 

Case  V. — Mr.  W.,  set.  23,  a  patient  sent  to  me  by  Professor  Fordyce  Barker, 
of  this  city.  Had  scarlet  fever  when  young,  and  since  that  time  has  suffered 
from  purulent  discharge  from  the  ear,  and  has  been  quite  deaf.  General 
health  is  excellent.  No  gouty,  rheumatic,  or  other  diathesis.  Hears  ordinary 
conversation  very  near  at  hand  with  very  great  difficulty.  The  watch  is  heard 
when  pressed  upon  right  meatus ;  not  at  all  on  left.  A  gelatinous  polypus 
was  found  attached  to  the  hypertropic  posterior  wall  of  the  auditory  canal.  It 
was  removed  by  torsion,  and  nitric  acid  applied  to  its  roots.  On  left  side  there 
is  a  pedunculated  bony  growth,  arising  from  the  posterior  wall,  nearly  occlud- 
ing caliber  of  canal.  Naso-pharyngeal  catarrh.  June,  1868 — Patient  has 
been  under  observation  since  first  date.  Now  hears  conversation  much  better  ; 
watch  at  a  distance  varying  from  one  to  two  inches  on  right  side.  Secretion 
of  pus,  which  when  patient  was  first  seen  was  profuse,  is  now  slight.  Growths 
remain  the  same. 

Case  VI.— Miss ,  set.  25.    March,  1873.    I  was  asked  by  Dr.  E.  G.  Lor- 

ing  to  assist  him  in  the  examination,  under  ether,  of  a  case  of  tumor  blocking 
up  the  external  auditory  canal,  with  a  view  to  its  removal  if  practicable.  The 
tumor  was  so  sensitive  to  the  touch  of  a  probe,  that  no  thorough  examination 
could  be  made.  The  patient  was  about  twenty-five  years  of  age,  and  had  suf- 
fered a  great  deal  from  what  she  called  rheumatism  of  the  back,  but  which 
seemed  to  have  been  neuralgia.  She  was  rather  small  and  delicate,  but  in  fair 
general  health.  She  was  placed  under  the  influence  of  ether,  and  a  thorough 
examination  was  made  by  Dr.  Loring,  Dr.  Pardee,  and  myself.  The  tumor 
arose  from  the  posterior  portion  of  the  osseous  canal  of  the  right  ear,  and 
nearly  occluded  the  passage.  There  was  a  minute  opening  between  it  and 
the  anterior  wall,  through  which  a  No.  2  Bowman's  probe  could  be  passed 
into  the  cavity  of  the  tympanum.  The  tumor  was  of  bone,  and  covered  by  a 
movable  integument,  which  was  red  and  very  sensitive.  On  passing  the  probe 
into  the  minute  opening  that  has  been  mentioned,  it  could  be  passed  under 
the  growth,  and  when  pressed  upon  the  growth  was  seen  to  move  slightly. 

The  history  of  the  case  was,  that  there  were  frequent  attacks  of  pain  in  the 
ear,  without  discharge,  until  the  patient  was  eleven  years  old,  since  which 


408  MASTOID  DISEASE. 

time  there  Las  been  no  true  "  ear-ache,"  and  no  discharge,  although  the  parts 
are  tender,  and  there  is  a  great  feeling  of  fulness  in  the  ear.  The  watch  is 
not  heard  at  all  on  the  affected  side.  The  tuning-fork  is  heard  better  than  in 
the  other  ear,  which  is  normal.  The  examination,  during  the  anaesthetic 
state,  of  the  tumor  by  the  probe,  caused  it  to  be  very  sensitive  when  the  patient 
recovered  from  the  ether.  The  aural  douche  was  used  to  quiet  the  pain.  The 
patient  was  advised  to  continue  to  use  the  douche ;  but  inasmuch  as  there  was 
no  pus  in  the  tympanic  cavity,  and  the  removal  of  the  growth  seemed  to 
involve  considerable  danger  from  periostitis,  any  further  treatment  was  delayed 
until  urgent  symptoms  should  arise.  May  8,  1873 — There  is  considerable  pain 
in  the  depth  of  the  ear,  and  Dr.  Loringand  I  advise,  that  some  operative  means 
be  taken  to  remove  the  growth. 

The  history  of  this  case  indicates  that  there  was  originally 
a  suppurative  action,  for  we  can  hardly  believe  that  very 
severe  pain  occurred  so  frequently  as  was  stated,  until  the 
patient  was  eleven  years  old,  with  no  suppuration.  The 
exostosis,  which  probably  then  began,  has  been  growing  ever 
since,  until  it  has  reached  the  present  limits,  where  it  seri- 
ously threatens  the  future  of  the  patient. 

MASTOID  DISEASE. 

As  we  have  seen,  in  considering  the  diseases  of  the  middle 
ear,  and  in  discussing  its  anatomy,  the  mastoid  process  is  neces- 
sarily involved  in  any  severe  inflammation  of  this  part  of  the 
organ  of  hearing.  This  may  also  be  the  case  in  an  acute  or 
chronic  inflammation  of  the  auditory  canal,  for  the  mastoid 
process  opens  into  this  part  also.  Yet  there  is  a  form  of 
mastoid  inflammation  which  assumes  such  importance,  and 
overshadows  the  inflammatory  action  in  other  parts  to  such 
a  degree,  that  it  demands  an  especial  study,  and  especial 
treatment.  The  usual  treatment  of  an  acute  inflammation  of 
the  external  and  middle  ear  soon  causes  the  symptoms  of  the 
inflammation  of  the  lining  membrane  of  the  mastoid  cavities 
to  subside  ;  but  when  the  mastoid  process  is  involved  in  the 
course  of  a  chronic  suppurative  process,  the  ordinary  treat- 
ment will  not  avail.  More  prompt  and  decisive  means  are 
usually  required.  Under  such  circumstances,  diseases  of  the 
mastoid  often  assume  such  proportions  of  severity  and  danger, 
that  we  are  justified  in  speaking  of  mastoid  disease  as  a  com- 


MASTOID   PERIOSTITIS.  409 

plication  requiring  especial  notice  and  treatment.  Perhaps  it 
is  a  complication  or  consequence  of  chronic  suppuration  in 
the  middle  ear,  only  second  in  gravity  to  an  extension  of  the 
inflammation  to  that  portion  of  the  dura  mater  covering  and 
running  into  the  tympanic  cavity. 

The  diseases  of  the  mastoid  that  may  arise  as  a  conse- 
quence of  a  chronic  inflammation  of  the  middle  ear  may  be 
divided  into  the  following  varieties  : 

1.  Inflammation  of  the  periosteum. 

2.  Caries  and  chronic  suppuration. 

It  is  true,  as  has  been  already  indicated,  that  the  first 
form  often  arises  in  the  course  of  an  acute  catarrh,  and  that 
it  perhaps  always  exists  to  a  more  or  less  extent  in  this  dis- 
ease ;  but  it  is  no  less  true  that  a  chronic  suppurative  process 
that  has  been  going  on  quietly  for  years  perhaps,  will  suddenly 
become  an  acute  inflammation  of  the  mucous  membrane  and 
periosteum  of  the  part,  and  require  especial  and  prompt  treat- 
ment. The  mucous  membrane  lining  the  mastoid  cells  is  so 
closely  connected  to  the  bone,  that,  like  the  mucous  membrane 
of  the  cavity  of  the  tympanum,  it  is  essentially  a  periosteum. 

Caries  and  necrosis  are  of  course  the  same  affections  that 
occur  so  frequently  in  other  parts  of  the  middle  ear,  and  from 
the  same  cause — imperfect  removal  of  the  pus  that  has  been 
forming. 

Sclerosis  and  hyperostosis  of  the  bone  has  also  been  con- 
sidered as  a  separate  morbid  condition  by  Agnew*  and  A.  H. 
Buck,t  but  as  admitted  by  the  latter  author,  the  cases  are  not 
yet  numerous  enough  to  allow  us  to  make  a  positive  diagnosis 
of  this  disease  from  clinical  facts.  We  are,  perhaps,  justified, 
in  this  practical  treatise,  in  classifying  this  class  of  cases 
under  the  head  of  periostitis. 

Symptoms. — The  symptoms  of  mastoid  periostitis  are  usu- 
ally sufficiently  striking  to  arrest  the  attention  of  the  medical 
adviser  so  soon  as  they  occur. 

During  the  course  of  an  acute  or  chronic  suppurative  pro- 
cess in  the  middle  ear,  the  patient  begins  to  complain  of  great 

*  Transactions  of  the  American  Otological  Society. 

•j-  Archives  of  Ophthalmology  and  Otology,  vol.  iii.,  No  1. 


410  MASTOID  PEKIOSTITIS — TKEATMENT. 

pain  behind  the  ear,  the  mastoid  process  becomes  red,  tender, 
and  swelled.  This  is  the  usual  course,  although  at  times  the 
pain  is  not  referred  especially  to  the  mastoid,  even  when  it 
is  evidently  involved,  as  shown  by  the  redness  or  tender- 
ness of  the  part.  The  pain  is  usually  of  the  severest  kind, 
preventing  the  patient  from  sleep  and  from  his  usual  occupa- 
tions, although  he  may  not  be  confined  to  the  house. 

The  early  diagnosis  of  this  affection  is  by  no  means  an 
unimportant  matter.  A  delay  in  the  recognition  of  the  true 
state  of  things  allows  of  the  extension  of  the  disease  to  the 
brain  through  some  of  the  numerous  foramina  which  transmit 
the  minute  branches  of  the  middle  meningeal  artery.  Pus 
may  also  be  carried  into  the  circulation  through  the  mastoid 
vein  which  passes  to  the  lateral  sinus. 

Professor  Alfred  C.  Post,  of  this  city,  who  was  one  of  the 
first  physicians  in  this  country  to  give  diseases  of  the  ear  the 
same  attention  that  was  paid  to  other  parts  of  the  body,  has 
seen  several  cases  where  disease  of  the  brain  and  death  have 
resulted  from  the  non-recognition  of  mastoid  disease. 

Many  neglected  cases  run  their  course,  however,  with  great 
suffering  to  the  patient,  and  with  much  loss  of  function,  with^ 
out  destroying  life.  This  is  proven  by  the  frequency  with 
which  mastoid  cicatrices  are  seen  in  our  aural  cliniques.  The 
history  of  such  patients  usually  shows  that  they  have  had  a 
narrow  escape,  but  that  nature  has  at  last  given  relief  by 
an  external  opening  through  which  the  pus  and  dead  bone 
made  their  way. 

Treatment. — The  treatment  of  mastoid  congestion  and  peri- 
ostitis is  very  simple.  An  incision  should  be  made  through 
the  integument  and  periosteum  down  to  the  bone.  The  inci- 
sion should  be  from  below  upward,  lest  the  knife  should  slip 
and  pass  into  the  tissues  of  the  neck.  The  opening  should 
not  be  a  puncture,  but  a  cut  of  from  three-quarters  to  an  inch 
and  a  half  long,  or  even  longer,  according  to  the  age  of  the  sub- 
ject. The  incision  should  be  parallel  to  the  attachment  of  the 
auricle.  Even  if  the  posterior  auricular  artery  be  wouuded,  the 
bleeding  can  be  readily  arrested  by  pressure  or  torsion.  I 
have  never  found  any  alarming  hemorrhage.     A  free  escape  of 


MASTOID   PERIOSTITIS — TREATMENT.  411 

blood  is  desirable.  The  surgeon  who  has  not  made  this  inci- 
sion in  cases  of  mastoid  periostitis  will,  perhaps,  be  surprised 
at  the  depth  of  the  tissues  when  they  have  become  infiltrated 
from  an  inflammatory  action  of  some  days  standing.  I  have 
sometimes  been  amazed  at  the  depth  to  which  the  scalpel 
entered,  especially  when  pus  has  formed.  Pus  will  not  be 
found  in  the  majority  of  the  cases,  but  the  indications  for  an 
early,  free,  and  deep  incision  are  imperative  when  we  find  red- 
ness, tenderness,  and  swelling  of  the  mastoid  process  in  con- 
nection with  an  inflammatory  process  in  the  ear. 

It  should  be  remarked,  however,  that  there  are  some  inno- 
cent cases  of  mastoid  disease  that  may  occur  in  the  course  of 
an  acute  catarrh — cases  that  will  not  demand  the  incision  that 
has  been  described.  Young  children,  especially  children  of  stru- 
mous habit,  at  times  suffer  from  an  infiltration  of  the  tissues 
of  the  mastoid,  which  may,  if  carefully  watched,  be  allowed  a 
little  more  delay  than  the  same  class  of  affections  occurring  in 
an  older  subject.  There  is  a  phlegmonous  inflammation  of  this 
part  occurring  in  young  subjects,  which  does  not  go  on  so 
rapidly  or  painfully  as  a  periostitis.  Still,  in  case  of  doubt,  it 
is  better  to  err  on  the  side  of  making  the  incision.  Furuncles 
in  the  auditory  canal  may  cause  an  oedema  of  the  parts  about 
the  mastoid,  that  will  not  require  an  incision.  A  little  care 
in  observation  will  show,  however,  that  while  these  cases  simu- 
late a  periostitis  in  the  swelling  and  redness,  there  is  not  the 
exquisite  tenderness  and  dreadful  suffering  of  a  true  periostitis. 
The  mastoid  gland  may  enlarge  during  the  course  of  an  acute 
catarrh,  or  in  strumous  subjects  who  have  no  aural  disease, 
but  such  an  enlargement  will  hardly  be  mistaken  for  a  peri- 
ostitis. 

If  the  incision  be  made  in  the  early  stages  of  mastoid 
periostitis,  pus  will  not  be  found,  but  the  relief  to  the  pain 
from  the  hemorrhage,  and  the  letting  up  of  the  great  tension 
of  the  inflamed  periosteum,  will  be  no  less  marked  than  if 
suppuration  has  occurred.  The  incision  will  be  as  useful  as 
the  division  of  the  periosteum  in  a  case  of  paronychia — a  com- 
parison which  Dr.  Post  has  been  in  the  habit  of  making  in 
lecturing  upon  these  cases.  The  incision  that  is  recom- 
mended for  the  relief  of  mastoid  periostitis,  was  first  urged 


412  MASTOID  PERIOSTITIS — CASES. 

upon  the  profession  by  Sir  "William  Wilde.  His  writings  upon 
the  subject  have  undoubtedly  saved  many  lives. 

After  the  incision  a  poultice  should  be  applied,  and  the 
opening  maintained  by  the  insertion  of  a  tent  a  longer  or 
shorter  time,  according  to  the  severity  of  the  accompanying 
symptoms.  The  importance  of  maintaining  the  opening  for 
some  time  in  cases  of  chronic  suppuration,  was  very  well  illus- 
trated by  the  following  case  : 

In  June,  1872, 1  saw  in  consultation  with  Dr.  E.  G.  Loring, 
a  somewhat  remarkable  case  of  chronic  suppuration  in  the 
middle  ear,  with  mastoid  periostitis,  in  a  gentleman  of  more 
than  seventy  years  of  age,  in  which  the  opening  was  main- 
tained by  Dr.  Loring,  by  means  of  trimming  up  the  edges  with 
scissors,  the  use  of  caustic,  a  drainage  tube,  and  so  forth,  for 
some  three  months.  Dr.  Loring  found  that  the  instant  the 
opening  was  allowed  to  close,  pain  in  the  back  of  the  head, 
and  in  the  depth  of  the  ear,  began  to  recur,  which  threatened 
even  the  life  of  the  old  gentleman  who  was  the  subject  of  the 
disease.  The  patient  finally  made  a  perfect  recovery  from 
the  mastoid  disease,  and  although  a  man  of  more  than  seventy 
years  of  age,  he  is  actively  engaged  in  the  daily  care  of  large 
business  affairs.  The  mastoid  periostitis  in  his  case  was  a 
consequence  of  an  unusually  severe  acute  suppuration  of  the 
middle  ear,  which  swept  away  the  drum-head  in  a  short  time. 

ILLUSTRATIVE  CASES  OF  MASTOID  PERIOSTITIS. 

The  two  first  of  the  following  cases  are  from  the  notes  of 
Dr.  David  "Webster,  House  Surgeon  in  the  Brooklyn  Eye  and 
Ear  Hospital,  where  they  were  under  my  care,  and  are  strik- 
ing evidences  of  the  prompt  relief  afforded  by  timely  interfer- 
ence: 

Case  I. — Chronic  Suppurative  Otitis  Media — Cessation  of  Discharge — Mastoid 
Periostitis — Incision — Recovery. 

Eliza  N.,  set.  18,  had  a  discharge  of  pus  from  the  right  ear  for  two  months. 
The  discharge  suddenly  ceased,  and  the  patient  was  attacked  with  severe 
pain  and  swelling  over  the  mastoid,  which  grew  worse  and  worse  for  several 
days,  and  caused  her  to  visit  the  hospital.  Dr.  Roosa  diagnosticated  mas- 
toid periostitis,  and  at  once  (May  10,  1869)  made  a  free  incision  down  to 


MASTOID  PERIOSTITIS— CASES.  413 

the  bone.  No  pus  was  found,  but  there  was  free  hemorrhage,  which  was 
encouraged  by  the  use  of  warm  water.  The  membrana  tympani  was  found  to 
be  removed  by  suppuration,  but  there  was  a  slight  discharge  from  the  canal. 
A  tent  was  placed  in  the  wound  and  a  poultice  applied  over  it.  May  11, 
patient  has  had  no  pain  and  has  slept  well.  The  tent  was  reapplied  and  the 
poultice  continued.  May  16,  the  swelling  of  the  mastoid  is  gone.  There  has 
been  at  ho  time  a  discharge  of  pus  from  the  incision,  but  there  was  a  copious 
one  from  the  meatus.  The  patient  was  very  pale  when  first  seen,  but  the 
administration  of  iron  and  the  cessation  of  pain  have  restored  the  normal  con- 
dition.    She  has  not  since  returned  to  the  hospital. 

Case  II. — Chronic  Suppurative  Otitis  Media— Mastoid  Periostitis  and  Caries 
— Incision — Recovery. 

Margaret  O.,  set.  48,  came  to  the  hospital  June  21,  1869.  Three  months 
previously  she  had  variola,  and  in  the  third  week  of  that  disease  a  purulent 
discharge  began  from  the  left  ear.  This  discharge  ceased,  when,  a  week 
and  a  half  ago,  great  pain,  preventing  sleep,  set  in.  There  was  found  to 
be  considerable  swelling  and  puffiness  above  the  ear,  with  tenderness  behind 
it,  but  no  swelling.  There  was  great  cedenia  of  the  eyelids,  and  the  patient 
seemed  to  be  in  great  agony.  The  auditory  canal  was  swelled,  but  scarcely 
any  pus  was  found  in  it.  Dr.  Roosa  made  incisions  down  to  the  bone  above 
and  behind  the  ear ;  from  the  latter  pus  escaped,  and  a  probe  passed  in  a  direc- 
tion slightly  upwards,  forwards,  and  downwards  into  the  mastoid  cells.  The 
surface  of  bone  about  this  opening  was  roughened.  The  same  treatment  as  in 
the  former  case  was  prescribed.  Hydrate  chloral  gr.  xv.  was  given  at  bed- 
time. Dr.  Webster  saw  the  patient  the  next  day,  when  the  pain  had  en- 
tirely ceased.  June  28,  no  pain  or  tenderness.  Politzer's  method  of  inflation 
was  practised,  and  the  warm  douche  used. 

July  12.  A  minute  opening  about  a  quarter  of  an  inch  from  the  attachment 
of  the  auricle  still  exists.  The  probe  passes  upwards  and  forwards  into  a 
superficial  opening  in  the  bone.  No  swelling,  pain,  or  tenderness  about  the 
ear.    The  membrana  tympani  has  healed.    Hears  the  watch  6". 

Case  III. — Chronic  Suppurative  Otitis  Media — Mastoid  Periostitis — Incision — 

Recovery. 

William  Gr.,  set.  30,  came  to  the  Manhattan  Eye  and  Ear  Hospital,  June 
13,  1870.  In  December,  1869,  he  first  experienced  a  sharp  pain  in  the  left 
ear,  which  was  most  severe  at  night.  This  pain  continued  for  two  months, 
at  the  end  of  which  time  a  discharge  occurred  from  the  ear,  which  has 
continued  more  or  less  until  now.  Two  months  later  the  mastoid  process 
became  swelled  and  tender,  and  it  was  opened  and  poulticed  by  a  physician. 
A  great  quantity  of  pus,  as  the  patient  says,  was  discharged,  and  the  pain, 
which  was  severe,  was  relieved.  About  four  weeks  after  this  the  pain  in  the 
ear  again  occurred,  and  the  patient  presented  himself  at  the  hospital.  He  pre- 
sented the  appearance  of  a  great  sufferer ;  he  was  pale  and  haggard,  Ms  hands 
were  tremulous,  and  his  countenance  was  anxious.  He  complained  of  great 
pain,  referred  to  the  depth  of  the  ear  and  to  the  head.    The  mastoid  process 


414  MASTOID  PEKIOSTITIS — CASES. 

was  red  and  hot,  but  not  swelled  or  tender.  The  auditory  canal  was  exceed- 
ingly sensitive.  The  membrana  tympani  had  been  removed  by  suppuration, 
and  there  was  a  thin  coating  of  pus  on  the  floor  of  the  cavity  of  the  tym- 
panum. Air  was  forced  into  the  middle  ear  by  Politzer's  method,  and  leeches 
were  applied  to  the  tragus  and  mastoid.  On  the  next  day  warm  water  was 
frequently  instilled. 

June  14.  The  pain  in  the  ear  has  decreased,  but  there  is  more  redness  of 
the  mastoid.  Leeches,  to  be  followed  by  a  poultice,  were  ordered.  I  did  not 
see  the  patient  after  his  second  visit,  in  consequence  of  my  absence  from  town, 
until  the  20th,  when  I  found  fluctuation  in  front  of  the  meatus,  as  well  as  great 
tenderness  over  the  mastoid,  with  an  increase  of  the  constitutional  symptoms. 
The  patient  was  then  admitted  as  an  in-patient,  and  having  given  him  a  dose 
of  whiskey  on  account  of  his  very  shattered  condition,  I  proceeded  to  make 
free  incisions  down  to  the  bone  in  front  of  and  behind  the  ear.  The  bone  was 
not  denuded  or  roughened.  A  tent  was  inserted  and  a  poultice,  the  latter  to 
be  renewed  every  three  hours.  The  patient  slept  well  that  night  for  the  first 
time  in  some  weeks,  taking  a  dose  of  fifteen  grains  of  hydrate  of  chloral. 

June  28.  The  patient  has  since  been  free  from  pain.  The  incisions  have 
nearly  healed.  There  is  a  slight  discharge  of  pus  from  the  auditory  canal. 
He  hears  a  watch  when  it  is  laid  upon  the  ear.  His  general  condition  is  now 
very  good,  and  he  is  discharged  at  his  own  request. 

It  is  somewhat  remarkable  that  this  patient  experienced  so 
many  painful  symptoms  of  mastoid  disease  for  so  long  a  time, 
and  yet  escaped  without  disease  of  the  bone.  His  affection 
was  never  more  than  an  affection  of  the  lining  membrane,  with 
some  periostitis,  while  in  a  case  about  to  be  detailed,  of  much 
less  severity,  death  of  the  bone  occurred,  and  meningitis,  with 
a  fatal  result,  supervened.  I  now  think  that  a  free  incision 
should  have  been  made  over  the  mastoid  when  I  first  saw  the 
patient,  although  there  was  then  only  some  redness  of  the 
process  and  no  tenderness,  the  pain  being  referred  to  the 
depth  of  the  ear.  In  the  light  of  my  present  experience,  in 
all  cases  where  there  is  deep-seated  pain  referred  to  the  cavity 
of  the  tympanum,  which  is  not  at  once,  that  is  to  say,  in  a  few 
hours,  relieved  by  leeching  and  the  warm  douche,  even  if  the 
mastoid  cells  do  not  seem  to  be  involved,  I  should  consider 
rayself  as  giving  the  patient  the  benefit  of  a  doubt  by  such  a 
depletion  as  a  free  incision  will  afford. 

Case  IV. — Chronic  Suppurative  Otitis  Media  of  years'  standing — Exacerbation 
— Mastoid  Abscess — Incision — Recovery. 

Case  IV. — Grade  B.,  aet.  13.  April  25,  1872,  I  was  summoned  to  New- 
burgh,  by  Dr.  S.  Ely,  to  see  a  case  in  consultation,  which  Dr.  E.  j  ustly  regarded 


MASTOID  PERIOSTITIS — CASES.  415 

as  urgent.  The  patient  was  a  healthy  girl,  who  had  had  a  discharge  from  hei 
left  ear  for  years,  and  who  for  the  past  few  weeks  suffered  from  an  exacerba- 
tion of  the  disease,  with  acute  symptoms.  Dr.  Ely  had  observed  that  the  mas- 
toid process  had  become  red,  and  swelled,  and  tender,  within  the  last  few  days. 
We  found  the  patient  in  bed,  and  evidently  in  great  suffering,  with  consider- 
able constitutional  disturbance,  hot  skin,  and  frequent  pulse.  The  neck  was 
very  much  swollen,  as  was  the  whole  integument  of  the  mastoid.  There  was 
a  profuse  discharge  of  pus  from  the  ear.  On  consultation  it  was  agreed  that 
an  opening  down  to  the  periosteum  should  be  made  at  once,  which  I  proceeded 
to  do,  the  patient  being  under  the  influence  of  ether.  The  opening  was  sur- 
prisingly deep,  so  that  the  knife  passed  through  three-quarters  of  an  inch  of 
tissue  before  the  bone  was  reached.  Pus  escaped  quite  freely.  The  wound 
and  the  ear  were  syringed  with  lukewarm  water,  and  an  examination  made 
for  a  fistula,  but  none  was  found.  The  bone  was  denuded  of  periosteum. 
The  membrana  tympani  had  been  long  since  removed  by  suppuration.  The 
patient  had  a  fair  night,  sleeping  without  an  anodyne,  and  rapidly  recovered 
after  the  opening  had  been  made.  A  poultice  was  applied  for  a  short  time,  and 
then  the  opening  was  allowed  to  heal.  The  ear  was  treated  in  the  usual  man- 
ner in  cases  of  chronic  suppuration. 

June  19,  1872.  The  patient  came  to  town  to  visit  me.  On  examination,  the 
membrana  tympani  was  found  to  be  removed  by  ulceration,  and  a  small 
amount  of  pus  lay  in  the  tympanic  cavity.  The  cicatrix  on  the  mastoid  is  one 
inch  long  and  one-half  inch  from  the  auricle.  The  patient  states  that  the 
wound  healed  in  about  one  week  after  it  was  made. 

Dr.  T.  Blanch  Smith,  of  Nyack,  lias  furnished  me  with  the 
notes  of  the  following  case  of  mastoid  disease,  which  termi- 
nated fatally.  Although  the  affection  of  the  mastoid  cannot 
be  said  in  this  case  to  have  been  a  consequence  of  a  chronic 
but  of  acute  suppuration,  it  is  none  the  less  instructive. 

Case  V. — Otitis  Media  Acuta,  with  Mastoid  Periostitis — Acute  Suppuration — 
Apparent  Recovery — Recurrence  of  Symptoms — Coma — Death. 

December  31,  1870, 1  visited  Mrs.  B.  V.,  set.  58,  and  found  her  suffering  from 
pain  in  the  left  ear  and  side  of  head,  moderate  febrile  excitement,  occasional 
rigors,  nausea,  and  vomiting  at  long  intervals.  There  was  much  tenderness 
over  the  left  mastoid  process  and  the  infero-posterior  margin  of  the  meatus 
externus.  Glances  which  I  obtained  of  the  membrana  tympani  did  not  reveal 
any  marked  change  in  its  color  or  shape. 

These  symptoms,  which  I  referred  to  acute  inflammation  of  the  tympanum, 
came  on  with  considerable  rapidity  about  thirty-six  hours  before  I  saw  the 
case,  and  were  clearly  traceable  to  an  antecedent  catarrhal  pharyngitis. 

The  sore-throat,  though  moderately  severe,  had  existed  two  weeks  before 
attention  had  been  attracted  to  any  ear  trouble,  and  had  been  allowed  to  run 
on  without  systematic  treatment  up  to  the  time  of  my  visit. 

Verat.  virid.,  nitrate  potash,  and  morphia  internally,  with  warm  water  and 


416  MASTOID  PERIOSTITIS. — CASES. 

laudanum  locally,  served  to  mitigate  considerably  the  distressing  symptoms 
until  on  January  3d,  the  fifth  day  from  the  commencement  of  the  aural  symp- 
toms, there  was  a  purulent  discharge  from  the  ear  followed  by  marked  allevia- 
tion, but  not  complete  removal,  of  pain.  Quinine  and  iron  were  next  used 
internally,  and  carbolic  acid  solution  locally. 

A  discharge,  pain  in  the  ear  (tolerably  severe  at  times),  and  decided  ten- 
derness over  mastoid  cells,  without  redness  of  surface  or  fluctuation,  continued 
to  about  January  9,  when  the  abatement  of  these  symptoms  was  so  decided 
that  the  patient  drove  out  in  a  closed  carriage,  and  her  general  health  con- 
tinued to  rapidly  improve  to  a  point  when  I  discontinued  regular  attendance. 

On  January  24,  not  having  seen  Mrs.  V.  for  four  days,  I  was  requested  to 
call  again.  I  learned  that  she  had  gone  on  very  smoothly  up  to  the  21st, 
when  she  found  that  the  discharge  had  ceased,  and  the  tenderness  and  pain 
were  gradually  becoming  intensified.  The  patient  thought  she  had  "  taken 
cold  in  tbe  ear  "  by  neglecting  to  carefully  protect  her  head  when  accompany- 
ing her  friends  to  the  outer  door.  Her  pains  I  found  were  now  more  severe 
than  before,  and  extended  from  the  meatus  over  the  sides  and  back  part  of  the 
head  and  neck.  There  was  neither  redness  nor  swelling  over  the  mastoid 
cells,  and  the  tenderness  was  less  acute  than  in  the  first  attack,  but  the  fever 
was  sharper,  nausea  more  persistent,  and  vomiting  more  frequent. 

With  the  addition  of  a  brisk  cathartic,  the  same  treatment  was  adopted  as 
in  the  early  period  of  the  disease.  On  the  25th,  I  found  my  patient  in  a  much 
less  comfortable  condition  than  I  had  anticipated,  the  distressing  symptoms 
not  having  been  so  decidedly  mitigated  by  the  prescription  as  on  previous 
occasions.  The  patient  seemed  exhausted  by  loss  of  sleep,  pain,  etc.  I  ordered 
the  anodyne  to  be  given  at  shorter  intervals  unless  the  pain  abated  or  sleep 
was  secured.  On  the  26th,  visited  Mrs.  V.  at  my  usual  hour,  and  on  meeting 
her  husband,  was  told  by  him  that  she  did  not  seem  any  better,  although  she 
was  very  drowsy  or  stupefied.  On  reaching  the  bedside,  I  saw  my  patient  was  in 
a  perilous  condition.  The  pupils  were  moderately  dilated  ;  conjunctiva  of  left 
eye  so  cedematous  as  to  protrude  between  the  partly  opened  lids,  and  deeply 
stained  by  large  ecchymoses  ;  respiration  42,  not  stertorous ;  pulse  128  ;  sur- 
face of  face  and  hands  livid  ;  top  and  back  part  of  head  hot ;  slight  discharge 
from  ear ;  no  convulsive  movements.  Mr.  V.  stated  that  at  11  p.  M.  preceding 
night,  she  complained  of  a  very  curious  and  unpleasant  sensation,  saying  she 
felt  as  if  she  wanted  "  to  fly  in  the  air,"  and  also  of  something  wrong  about 
her  eyes,  repeating,  "  I  can't  see  anything."  These  peculiar  sensations  and 
expressions  the  husband  attributed  to  the  effects  of  morphia,  and  so  was  not 
specially  alarmed  until  I  told  him  I  thought  her  in  a  hopeless  condition.  She 
continued  to  sink,  without  remarkable  change  in  the  symptoms,  until  she  died, 
fifty -eight  hours  from  the  development  of  these  grave  features  of  the  case. 


CAEIES  AND  SUPPURATION  OP  THE  MASTOID. 

Caries  of  the  mastoid  is  an  extension  of  the  inflammatory 
process  that  has  been  described  under  the  head  of  periostitis. 
The  pathology  of  caries  of  this  bone  is  well  described  by 


CAEIES  AND  SUPPURATION  OF  THE  MASTOID.  417 

A.  H.  Buck,*  as  follows  :  "  The  cells  being  filled  with  a  swelled 
and  congested  mucous  membrane,  a  stasis  occurs  in  the  local 
circulation,  the  bone  is  not  well  nourished,  and  the  contents 
of  the  cells  break  down  into  pus.  The  bony  partitions  then 
become  dissolved,  a  granular  detritus  is  formed,  or  the  bony 
parts  separate  as  a  whole  from  the  surrounding  healthy  parts." 
This  form  is,  of  course,  more  dangerous  than  mere  periostitis ; 
and  yet  cases  of  caries  and  necrosis  are  sometimes  relieved  at 
the  great  cost  of  unnecessary  suffering  to  the  patient,  by  Na- 
ture's slow  process  of  casting  out  diseased  bone.  After  the 
detailed  account  that  has  been  given  of  the  symptoms  of  mas- 
toid periostitis,  it  is  perhaps  unnecessary  to  dwell  at  length 
upon  the  clinical  features  of  caries  and  necrosis.  It  is,  more- 
over, oftentimes  impossible  to  draw  the  line  between  a  case  of 
periostitis  and  one  of  caries. 

In  many  cases  the  symptoms  of  caries  of  the  mastoid  do 
not  differ  essentially  from  those  of  mastoid  periostitis.  There 
is  then  the  same  redness,  tenderness,  and  swelling  of  the 
process,  attended  by  deeply  seated  and  intense  pain.  In 
others,  however,  the  redness,  tenderness,  and  swelling  are 
entirely  absent,  while  the  pain  referred  to  the  depth  of  the 
ear,  will  be  the  only  marked  symptom.  This  pain  is  not 
relieved  by  leeches,  and  anodynes  will  only  veil  the  symptoms 
for  a  brief  period.  Usually,  however,  even  in  the  insidious 
cases,  tenderness  will  be  shown  upon  firm  pressure  on  the 
part.  Yet  the  surgeon  may  cut  down  upon  a  bone  to  find  it 
diseased,  when  he  had  not  been  previously  able  to  positively 
diagnosticate  this  state  of  things.  It  may  be  said,  however, 
in  general  terms,  that  any  deep-seated  pain  referred  to  the 
mastoid  or  its  region,  occurring  in  the  course  of  an  inflamma- 
tion of  the  ear,  should  be  looked  upon  with  suspicion,  even  if 
there  be  no  redness,  tenderness,  or  swelling  of  the  process 
itself. 

The  auditory  canal  is  often  involved  in  cases  of  caries  of 
the  mastoid.  A  fistulous  opening  is  sometimes  found  leading 
from  this  part  into  the  mastoid  cells,  in  which  case,  granula- 
tions are  usually  found  in  the  canal.     The  presence  of  granu- 

*  Archives  of  Ophthalmology  and  Otology,  vol.  iii.,  No.  1. 

27 


418       CAEIES  AND  SUPPUEATION  OF  THE  MASTOID. 

lations  in  the  canal  should  lead  us  to  examine  the  part  very 
carefully  to  see  if  a  fistula  may  not  be  found.  As  will  be  seen 
by  reference  to  Case  I.,  dead  bone  may  sometimes  be  removed 
through  the  canal.  A  clinical  fact  of  some  importance  in  the 
diagnosis  of  mastoid  disease,  is  the  one  that  the  chronic  or 
acute  suppurative  process  in  the  middle  ear,  is  often  very 
much  less  violent,  or  entirely  checked  at  the  time  of  the  out- 
break of  the  periostitis.  This  fact  applies  to  both  forms  of  the 
disease.  Yet  it  is  a  mistake  to  suppose  that  mastoid  perios- 
titis, or  caries,  may  not  occur  while  a  free  discharge  of  pus 
is  taking  place  from  the  ear.  While  these  pages  are  passing 
through  the  press,  I  am  treating  an  acute  case  of  mastoid  sup- 
puration and  caries,  in  which  the  discharge  from  the  auditory 
canal  is  profuse. 

Treatment. — The  first  step  in  the  treatment  of  a  case  of 
supposed  caries  of  the  mastoid,  is  to  divide  the  tissues  over 
the  process  down  to  the  bone,  as  was  recommended  for  cases 
of  mastoid  periostitis.  If  a  fistula  be  found,  it  will  be  simply 
necessary  to  enlarge  this,  so  as  to  give  a  free  exit  to  the  pus. 
If  the  bone  be  very  soft,  a  stiff  probe  will  sometimes  be  suffi- 
cient, but  usually  a  small  drill  will  be  required.  If  there  be 
no  fistula,  and  we  have  decided  that  dead  bone  is  probably 
beneath  the  outer  table,  a  small  trephine  may  be  used,  and 
the  process  opened — the  periosteum  being,  of  course,  first  dis- 
sected up.  The  trephine  should  be  worked  in  a  direction 
inwards,  forwards,  and  upwards.  There  can  be  no  positive 
directions  given  as  to  the  depth  to  which  the  instrument 
should  go.  By  reference  to  the  anatomy  of  the  mastoid  pro- 
cess (page  206),  it  will  be  seen  that  the  thickness  of  the  outer 
layer  of  bone  varies  somewhat  in  different  cases.  The  opera- 
tion should  go  on  very  slowly,  frequent  pauses  being  made  to 
see  how  deep  the  instrument  has  gone.  It  is  impossible  to 
say  in  a  given  case  at  what  depth  we  shall  reach  the  cells,  or 
free  spaces,  and  thus  make  an  outlet  for  the  pus.  Dr.  Agnew 
was  obliged  to  go  to  the  depth  of  five-eighths  of  an  inch  in 
one  of  his  cases,  and  then  found  only  sclerosed  bone.  Dr. 
D.  C.  Ambrose,  of  this  city,  removed  a  piece  one  inch  long  from 
the  mastoid  process  of  a  young  woman  of  twenty  years  of  age. 


CAEIES  OP  THE  MASTOID — TREPHINING.  419 

The  cell  structure  will  ordinarily  be  found  at  a  depth  of  from 
one-sixth  to  one-fourth  of  an  inch.  In  infants  the  outer  shell 
of  bone  is  so  thin  that  true  trephining  will  probably  never  be 
required ;  but  any  firm  instrument  will  make  the  required  open- 
ing. In  case  of  an  emergency,  a  surgeon  has  been  known 
to  use  a  common  gimlet,  to  open  the  mastoid  process  (see 
Case  III.).  The  lateral  sinus  will  always  be  avoided  by  keep- 
ing the  instrument  as  directed  above. 

The  after  treatment  is  the  same  as  that  of  an  operation  for 
necrosis  in  other  bones.  The  wound  should  be  dressed  from 
the  bottom  with  lint,  and  kept  open  for  some  time.  The  pa- 
tient should  be  kept  free  from  all  noise  and  excitement. 

Historical. — The  history  of  the  operation  of  trephining  or 
opening  the  mastoid  process,  is  an  interesting  one.  It  is 
here  given  as  it  appeared  in  an  article  upon  the  affections  of 
the  mastoid  by  myself,  with  some  amplifications,  that  a  subse- 
quent investigation  have  allowed  me  to  make.* 

From  a  monograph  on  this  subject  by  J.  Arneman*  Pro- 
fessor in  the  University  of  Gottingen,  published  in  1792,  we 
learn  that  Eiolanus  (in  1649,  according  to  Adolph  Murrayt), 
was  the  first  author  who  inquired  into  the  propriety  of  per- 
forating the  mastoid  process  in  cases  of  occlusion  of  tJie  Eusta- 
chian tube,  for  the  purpose  of  removing,  by  injections  through 
the  opening,  morbid  secretions  in  the  mastoid  cells  and  cavity 
of  the  tympanum.  Eollfink,  afterwards,  in  an  anatomical  dis- 
sertation, published  at  Jena  in  1656,  also  advocated  the  opera- 
tion. J.  L.  Petit,  according  to  Von  Troltsch,J  was  the  first 
who  actually  performed  the  operation,  which  he  did  by  means 
of  a  gouge  and  hammer. 

Then  we  come  to  Valsalva's  case,  published  nearly  a  hun- 
dred years  after  the  suggestion  of  Eiolanus,  which  has  been 
claimed  by  all  the  authors  as  a  case  of  perforation  of  the  mas- 
toid, and  injection  through  it  of  the  middle  ear.  One  writer 
(Von  Troltsch)   states  that  an  otorrhoea  was  thus  cured  by 

*  Transactions  of  American  Otological  Society,  1870. — Medical  Record,  1870. 
\  Lincke's  Sammlung,  IV.,  p.  33. 

X  Bemerkungen  iiber  die  Durckbokring  des  Processus  Mastoideus  in  ge- 
wissen  Fallen  der  Taubkeit. 


420  VALSALVA  ON  MASTOID  FISTULA. 

Valsalva.  I  have  examined  the  original  passage  in  order  to 
verify  this  claim  made  for  Valsalva,  and,  if  I  am  correct,  there 
is  no  such  claim  by  Valsalva  himself.  He  simply  states  that 
he  injected  a  fistula  existing  in  this  part,  in  the  case  of  a 
nobleman  ;  with  what  result  he  does  not  say.  The  following 
is  the  side-note  to  the  passage  :*  "  Observatio  ulceris  processam 
mamiUarem,  per  quod  injecta,  statim  in  oris  cavitatem,  licet  unde- 
quaque  illasam  transmittebantur."  The  passage  itself  is  as  fol- 
lows :  "  Adeoque  mitto  prolixius  confirmare  per  quondam  meam 
in  viro  humane  observationem,  de  nobili  scilicet  viro,  ulcere  ad  pro- 
cessum  mamiUarem,  cum  hujus  carie  laborante  in  quod  quce  ivjicie- 
bantur,  illico  ad  fauces  perveniebant  adeoque  a  tympano,  quo  per 
illius  processus  sinuositaies  ascendebant,  per  tnbam  certe  derive- 
bantur^  etc. 

I  have  ventured  to  translate  the  passage  with  some  free- 
dom, but  with  correctness,  as  follows.  After  speaking  of  the 
Eustachian  tube  as  a  passage  to  the  pharynx,  Valsalva  says  : 
"  I  beg  to  confirm  what  I  have  said,  by  an  observation  made 
on  the  living  subject,  a  nobleman,  who  was  affected  with  caries 
of  the  mastoid  process.  The  fluids  that  were  injected  into 
this  ulcer  passed  through  the  sinuosities  of  the  mastoid  pro- 
cess into  the  tympanum,  and  thence  through  the  tube  to  the 
fauces." 

Valsalva  is  here  demonstrating  the  function  of  the  Eusta- 
chian tube.  He  makes  no  claim  to  have  perforated  the  mas- 
toid, but  he  simply  asserts  that  he  has  injected  a  fistula  in  the 
mastoid,  and  that  the  fluid  thus  injected  passed  into  the  mouth. 
I  cannot  find  any  evidence  in  the  passage  or  the  context  that 
his  patient  was  cured  of  an  obstinate  otorrhcea,  as  asserted  by 
Von  Troltsch,  so  that  I  think  Valsalva  must  be  left  out,  so  far 
as  any  evidence  from  this  passage  goes,  in  the  enumeration  of 
those  who  have  recommended  or  performed  the  operation  of 
which  we  are  speaking. 

The  surgeon  to  whom  we  are  indebted  for  having  fairly 
established  opening  of  the  mastoid  as  a  legitimate  surgical 
procedure,  is  Jasser,f  a  regimental  surgeon,  who,  in  1776,  first 
performed  it.     His  patient  was  a  soldier,  who  had  suffered  for 

*  Tractatus  de  aure  Humana,  1742,  p.  89. 
f  Lincke's  Sammlung,  Bd.  IV.,  p.  195. 


JASSERS  AND  BERGER'S  OPERATIONS.  421 

many  years  from  suppuration  and  pain  in  the  ears,  which  was 
not  relieved  by  active  but  judicious  antiphlogistic  treatment. 
In  this  case  there  was  an  abscess  of  the  mastoid,  and  death  of 
the  bone, — and  thus  the  operation  was  performed  under  indi- 
cations which  any  good  surgeon  of  the  present  day  would 
accept  as  peremptory.  Although  Jasser's  operation  was  a 
creditable  one  to  its  author,  it  has  been  misunderstood,  and 
classed  by  Wilde  in  the  list  of  the  same  operations  performed 
with  such  indications  as  "  obstinate  deafness." 

Arneman,  in  the  pamphlet  before  alluded  to,  details  five 
other  cases,  from  Fielitz,  in  which  the  operation  was  per- 
formed, and  claims  that  in  only  one  was  there  a  bad  result, 
and  then  death  ensued.  He  admits,  however,  that  it  may  be 
performed  without  avail.  The  bad  result  occurred  in  the  case 
of  Berger,  a  Danish  surgeon,  who  caused  it  to  be  performed 
on  himself,  and  died  of  meningitis  induced  by  the  opera- 
tion. Berger  had  suffered  for  years  from  very  great  vertigo 
and  noise  in  the  ears,  and  gradually  lost  his  hearing  power. 
He  got  no  relief  from  the  ordinary  means  of  treatment,  and 
his  malady,  which  placed  him  out  of  the  society  of  his  friends, 
troubled  him  very  much.  He  finally  determined  to  have  the 
operation  of  trephining  the  mastoid  performed,  in  order  to 
inject  the  parts  and  remove  the  hardened  secretion.  Berger 
evidently  suffered  from  what  we  should  now  term  chronic  pro- 
liferous inflammation  of  the  middle  ear ;  and  viewed  in  the 
light  of  our  present  knowledge,  there  was  no  proper  indication 
for  the  operation  of  trephining  the  mastoid.  Dr.  Kolpin  per- 
forated the  process  to  the  depth  of  three  lines.  The  incision 
does  not  seem  to  have  reached  the  cells,  for  an  injection  made 
in  the  opening  did  not  pass  into  the  throat.  On  the  day  after 
the  operation  a  chill  occurred.  These  chills  continued  to 
recur,  and  on  the  twelfth  day  Dr.  Berger  died.  Adhesions 
of  the  dura  mater  to  the  skull  were  found,  and  effusion  of  a 
transparent  gelatinous  fluid  between  the  arachnoid  and  pia 
mater,  as  well  as  over  the  whole  surface  of  the  cerebrum  and 
cerebellum. 

The  second  case  detailed  by  Arneman,  has  no  more  accu- 
rate statement  as  to  the  pathological  condition  of  the  ears  of 
the  patient  upon  whom  it  was  performed,  than  that  he  teas 


422  TREPHINATION  OF  MASTOID. 

wholly  deaf  in  both  ears.  The  operation  did  no  good,  but 
caused  temporary  blindness  and  faintness.  In  the  third  case 
there  is  also  no  account  of  the  cause  of  the  deafness  :  the  re- 
sult was  an  improvement  of  the  impaired  hearing  as  long  as 
the  wound  was  kept  open.  The  opening  was  maintained  by 
means  of  a  leaden  probe  until  cicatrization  occurred. 

The  fourth  case  was  that  of  an  old  lady,  who  had  lost  her 
hearing  from  a  quartan  fever.  She  had  noise  in  both  ears. 
The  process  was  perforated,  and  injections  of  lukewarm  water, 
which  passed  out  of  the  nostrils,  were  made.  After  the  injec- 
tions had  been  made  for  four  days  there  was  a  complete  resto- 
ration of  the  hearing  (sic),  while  the  openings  closed  readily. 

The  fifth  case  was  one  of  chronic  suppuration  in  the  ear, 
with  acute  exacerbations.  The  result  was  a  cure,  after  injec- 
tions for  twelve  days. 

These  statements  must  of  course  be  taken  with  some 
allowance,  inasmuch  as  with  the  exception  of  two  cases — the 
first  and  the  last — there  is  no  exact  knowledge  of  the  disease 
causing  the  symptoms  of  deafness  and  tinnitus.  But  even 
these  show  that  perforation  of  the  mastoid  is  not  a  dangerous 
procedure,  and  that  when  performed  under  such  indications 
as  those  in  Jasser's  case,  it  is  not  only  a  very  simple,  but  a 
very  beneficial  operation. 

In  Frank's  treatise  on  the  ear  several  cases  are  alluded  to ; 
but  here  also  the  indications  which  direct  their  performance 
are  wanting,  and  they  are  consequently  useless  as  guides  to 
the  surgeon. 

A  surgeon  named  Weber,  in  1825,*  made  an  opening  into 
the  mastoid  in  a  case  of  caries  of  the  bone,  but  evidently  with 
great  anxiety,  lest  he  might  not  undertake  a  sound  surgical 
procedure,  although  his  patient  had  symptoms  which  would 
not  allow  us  to  hesitate  for  a  moment.  He  used  a  trocar,  and 
went  about  three  lines  before  he  came  to  the  cells.  The  pa- 
tient recovered. 

Arneman,  in  a  style  of  surgical  writing  which  has  now, 
happily  for  us  with  our  more  accurate  knowledge,  passed 
away,  lays  down  the  following  indications  for  the  performance 

*  Lincke's  Sammlung,  Bd.  IV.,  p.  90. 


TEEPHINATION   OF  MASTOID.  423 

of  the  operation.  They  are  inserted  here  in  order  that  the  dis- 
trust with  which  surgeons  have  looked  upon  interference  with 
the  mastoid  process  in  aural  disease,  may  be  accounted  for. 

I. — In  any  case  of  absolute  deafness,  or  in  any  case  where 
the  impairment  of  hearing  is  constantly  increasing,  and  for 
which  all  other  remedies  have  been  used  without  effect. 

II.— When,  in  case  of  an  ulcer  or  suppuration  of  the  ear, 
the  morbid  material  has  become  collected  in  the  cells  of  the 
mastoid,  or  the  cells  have  become  carious.  (This  is  certainly 
a  good  indication,  and  the  one  upon  which  Jasser  acted.) 

III. — If  the  normal  mucous  secretion  has  become  hardened 
or  collected  in  excessive  quantity. 

IY. — In  cases  where  pain  and  noise,  which  would  finally 
destroy  the  hearing,  have  existed  in  the  ear  for  a  very  long 
time. 

V. — In  cases  of  stoppage  of  the  Eustachian  tube  not  reme- 
died by  injections. 

The  simple  operation  of  creating  an  external  opening  for 
retained  pus,  and  thus  preventing  its  passage  to  the  brain 
and  into  the  circulation,  was  thus  so  distorted  from  its  proper 
application,  by  the  improper  indications  for  its  performance, 
that  the  leading  writers  seem  to  have  been  in  as  great  a  state 
of  bewilderment  about  it  as  were  the  English  and  American 
surgeons,  until  a  few  years  since,  in  regard  to  the  use  of  the 
Eustachian  catheter.  The  text-books  either  mention  it  to 
condemn  it,  or  in  such  a  way  as  to  plainly  show  that  they  do 
not  realize  the  true  indications  for  its  performance. 

So  valuable  a  work  as  that  of  Wilde,  for  example,  con- 
founds such  an  operation  as  that  performed  by  Jasser  with 
the  others  quoted  by  Arneman,  which  were  undertaken  because 
the  first  operation  had  been  successful,  and  without  any  regard 
to  the  condition  of  the  ear,  but  for  the  relief  of  a  symptom — 
deafness. 

In  the  general  advance  of  our  exact  knowledge  of  diseases 
of  the  ear,  the  merits  of  the  operation  of  perforating  the  mas- 
toid were  again  discussed,  and  it  has  now  been  replaced  where 
Jasser  first  placed  it,  on  a  sound  basis.  Von  Troltsch,  in 
1861,  reported  a  case  of  acute  suppuration  in  the  middle 
ear,  with  perforation  of  the  membrana  tympani,  in  which  he 


424  INDICATIONS  FOE  TEEPHINING  THE  MASTOID. 

opened  the  mastoid  with  a  probe,  some  days  after  he  had 
made  Wilde's  incision  with  only  partial  relief. 

In  such  disrepute  was  this  operation  at  that  time,  because 
of  the  unhappy  fate  of  Berger,  who  caused  it  to  be  performed 
with  no  good  indications,  that  Von  Troltsch  confesses  that  he 
would  have  hesitated  to  undertake  this  simple  surgical  proce- 
dure with  any  but  the  instrument  which  he  employed.  The 
case  was  a  successful  one.  Eight  cases  are  reported  by 
Troltsch ;  that  of  Petit  is  considered  the  first,  and  Jasser's  the 
second ;  but  Valsalva's  injection  of  a  fistula  already  existing  is 
considered  as  an  operation. 

Jacoby*  has  especially  put  the  profession  under  obligations 
by  his  valuable  reports  of  cases,  with  the  indications  for  the  per- 
formance of  the  operation.  Very  recently  Koppe  and  Schwartze 
report  a  case  of  epilepsy  caused  by  retained  pus  in  the  middle 
ear,  which  was  relieved  by  perforation  of  the  mastoid. 

In  concluding  this  subject,  before  giving  the  illustrative 
cases,  the  conditions  under  which  the  mastoid  may  be  properly 
operated  upon,  either  in  periostitis  or  caries,  may  be  formu- 
lated as  follows  : 

I. — The  integument  and  periosteum  should  be  freely  di- 
vided over  the  mastoid  in  all  cases  in  which  there  is  pain, 
tenderness,  and  swelling  in  the  part. — (Wilde.) 

II. — Such  an  incision  should  also  be  made  whenever  severe 
pain,  referred  to  the  middle  ear,  exists,  and  is  not  relieved 
by  the  usual  means,  i.  e.,  leeches,  warm  water,  etc. 

III. — An  explorative  incision  should  be  made  when  we 
have  good  reason  to  suspect  the  existence  of  caries  and  re- 
tained pus  in  this  part. 

IV. — The  mastoid  bone  should  be  perforated  after  such  an 
incision  wherever  the  bone  is  found  diseased,  or  a  small  fistu- 
lous opening  should  be  enlarged.  It  should  also  be  perforated 
when  we  have  good  reason  to  believe  that  there  is  pus  in  the 
middle  ear  or  mastoid  cells  which  cannot  find  an  exit  by  the 
external  auditory  canal. 

V. — The  mastoid  should  be  perforated  in  the  case  of  a 
suppuration  of  long  standing,  with  frequent  and  painful  ex- 
acerbations. 

*  Arckiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  212. 


MASTOID  CARIES — CASES.  425 

The  operation  may  now  be  sure  to  be  fairly  established, 
and  is  frequently  undertaken,  it  having  been  performed  by 
Follin,  Schwartze,  Pagenstecher,  Hinton  (London),  Jacoby, 
Agnew  (New  York),  Colles  (Dublin),  and  by  myself  since  1859. 

Dr.  A.  H.  Buck  has  appended  to  his  article  on  mastoid 
disease,  from  which  I  have  quoted,  a  table  containing  thirty- 
four  cases  of  opening  the  mastoid,  beginning  with  Arneman. 
Drs.  Weir,  Laight,  and  Buck  of  this  city,  Drs.  Newton  of 
Brooklyn,  and  North  of  Waterbury,  Conn.,  are  among  the 
surgeons  who  have  operated  since  1870,  and  this  sound  sur- 
gical procedure  may  be  said  to  be  fairly  established  in  the 
profession.  Twenty-six  of  the  thirty-four  cases  reported  by 
Buck  resulted  in  recovery. 

CASES. 

It  would  be  easy  to  insert  very  many  cases  of  trephination 
of  the  mastoid  that  are  now  to  be  found  in  the  literature  of 
otology,  but  in  adherence  to  the  plan  of  this  work,  a  few  are 
selected  which  will  clearly  exhibit  the  symptoms  of  caries  of 
the  mastoid,  and  the  clinical  facts  of  those  cases  for  which 
perforation  of  the  process  is  performed. 

Case  I. — Otitis  Suppurativa  Media — Caries  of  Mastoid — Incision  through 
Periosteum — Removal  of  Sequestrum  through  External  Auditory  Canal — 
Recovery. 
This  was  under  my  care  at  the  Manhattan  Eye  and  Ear  Hospital,  and  has 
already  been  reported  by  Dr.  C.  I.  Pardee,*  but  chiefly  with  reference  to  its 
being  a  case  of  otitis  media,  caused  by  the  use  of  the  nasal  douche.  I  saw  this 
patient,  who  was  a  man  of  about  thirty-five  years  of  age,  soon  after  the  inflam- 
mation of  the  ears  had  occurred,  which  was  about  nine  months  before  he  pre- 
sented himself  at  the  hospital  in  October,  1889.  He  was  then  suffering  from  a 
suppurative  inflammation  of  the  middle  ear,  but  the  amount  of  pus  discharged 
through  the  perforation  in  the  membrana  tympani  was  slight.  There  was 
considerable  swelling  of  the  mucous  membrane  of  the  cavity  of  the  tympanum, 
and  the  hearing  was  greatly  impaired.  He  could  not  hear  a  watch  at  all. 
He  was  under  my  care  for  this  suppuration  of  the  ears  for  eight  weeks,  when 
he  disappeared,  and  I  nest  saw  him,  as  just  stated,  some  nine  months  after,  at 
the  hospital,  when  I  found  his  condition  had  become  worse,  and  that  it  was 
alarming.  He  complained  greatly  of  pain  in  the  head,  which  prevented  him 
from  pursuing  his  avocation,  which  was  that  of  a  plumber.     The  auditory 

*  New  York  Medical  Gazette,  vol.  vi.,  No.  23. 


426  MASTOID   CARIES — CASES. 

canal  of  the  left  side  was  filled  with  granulations,  the  mastoid  process  was  red, 
tender,  and  painful.  Just  in  front  of  the  meatus  there  was  an  abscess,  and  a 
small  fistulous  opening  just  above  the  same  part.  The  hearing  on  that  side, 
as  tested  by  the  watch  and  voice,  was  completely  gone.  On  the  other  side,  the 
ear  was  in  substantially  the  same  conditiou  as  when  I  first  saw  him. 

I  immediately  made  incisions  down  to  the  bone,  rather  against  the  patient's 
will,  just  behind,  above,  and  in  front  of  the  attachment  of  the  auricle.  I  found 
no  dead  or  exposed  bone,  but  quite  a  large  amount  of  pus  was  evacuated.  The 
patient  immediately  began  to  improve.  In  a  few  days  Dr.  Pardee  removed  a 
piece  of  the  mastoid  structure  through  the  auditory  canal,  the  pain  in  the  head 
disappeared,  the  suppuration  from  the  mastoid  ceased,  the  granulations  were 
removed  from  the  canal,  and  the  patient  resumed  his  occupation. 

The  notes  of  the  following  case,  except  so  far  as  they  relate 
to  matters  observed  by  myself,  were  furnished  me  by  Dr. 
Hubbard,  of  Bridgeport,  through  whom  I  saw  the  patient. 

Case  II. — Sub-acute  Aural  Catarrh — Membrana  Tympani  intact — Suppura- 
tion in  Mastoid  Cells — Opening  of  Mastoid  Process — Death. 

Dr.  Hubbard  was  consulted  in  December,  1869,  "  by  W.  E.  S.,  get.  38,  by 
profession  a  mechanic,  with  good  physical  development  and  unexceptionable 
habits,  on  account  of  a  severe  influenza,  from  which  he  was  suffering,  and 
which  was  at  that  time  epidemic  in  this  city  (Bridgeport).  His  mother  and 
one  sister,  I  have  reason  to  believe,  died  of  tubercular  inflammation.  Hitherto 
he  had  suffered  no  severe  illness  since  the  ordinary  diseases  of  childhood,  from 
all  of  which  he  made  perfect  recoveries.  The  attack  of  influenza  was  charac- 
terized by  severe  irritation  of  the  whole  respiratory  system,  with  marked 
impairment  of  the  special  senses  of  taste  and  smell.  The  auditory  apparatus 
was  not  at  first,  however,  specially  implicated.  I  prescribed  for  his  'cold' 
several  times  during  the  acute  stage,  as  an  office  patient.  But  he  at  those 
visits  made  no  mention  of  any  trouble  about  his  ears.  Later  he  reported  that 
he  had  lost  his  cough,  but  complained  of  catarrh  of  the  fauces  and  nasal  pas- 
sages, for  which  I  prescribed  the  nasal  douche,  and  gargles  made  stimulant 
and  astringent  by  alum,  chlorate  of  potash,  chlorate  of  sodium,  tannin,  etc. 
To  the  use  of  these  he  ascribed  considerable  improvement.  I  then  lost  sight 
of  him  until  about  the  first  of  April,  1870,  when  he  consulted  me  on  account 
of  an  annoying  tiunitus  affecting  only  the  right  ear.  At  the  same  time  he 
reported  that  he  had  occasionally,  for  several  weeks  immediately  preceding, 
suffered  moderate  hemicrania  of  the  affected  side.  Inspection  showed  marked 
enlargement  of  the  mastoid  process,  which  he  declared  had  been  at  no  time 
the  seat  of  pain,  and  yielded  no  suffering  under  firm  pressure.  Specular  exam- 
ination showed  a  moderate  degree  of  congestion  of  the  membrana  tympani, 
and  by  Politzer's  method  the  Eustachian  passage  was  found  to  be  pervious. 
The  middle  ear  was  occasionally  inflated,  however,  and  warm  water  injections 
to  the  meatus  externus  ordered  daily  at  bedtime,  and  a  blister  directed  to  be 
applied  over  the  mastoid  process.  At  the  same  time  I  continued  constitutional 
treatment  by  quinine,  iron,  and  strychnia,  as  he  had  been  the  subject  some 


MASTOID  CAEIES — CASES.  427 

time  previously  of  malarial  infection.  Under  this  course  the  apparent  conges- 
tion of  the  membrana  tympani  disappeared,  but  the  tinnitus  was  in  no  degree 
diminished.  At  this  stage  of  the  case,  having  met,  as  well  as  I  was  able,  all 
rational  indications,  leaving  to  me  only  an  empirical  course,  I  advised  him  to 
consult  Professor  Roosa,  and  he  advised  me  to  renew  the  blister  to  the  mas- 
toid region,  also  to  apply  a  leech  to  the  tragus,  and  repeat  it  after  a  stated 
interval,  after  which  he  requested  to  see  him  again." 

My  notes,  on  seeing  the  patient,  are  :— Hearing  distance,  right  side,  2", 
tested  with  a  watch  that  should  be  heard  3' ;  membrana  tympani  opaque  ;  no 
light  spot ;  handle  of  malleus  injected.  A  very  feeble  current  of  air  passes  into 
the  Eustachian  tube.  Patient  complains  of  a  very  annoying  buzzing  sound  in 
his  ear.  There  is  a  very  slight  want  of  symmetry  in  the  mastoid,  no  pain 
referred  to  it,  no  tenderness  in  any  part  of  it ;  no  pain  in  the  ear.  Two  leeches 
ordered  to  the  tragus  and  a  blister  to  the  mastoid.  One  week  later  I  again 
saw  the  patient ;  the  symptoms  were  the  same.  He  had  had  some  pain  in  the 
ear  one  night  since  his  visit.  I  injected  steam  into  the  middle  ear,  and  sug- 
gested that  leeches  be  again  applied. 

(I  again  copy  Dr.  Hubbard's  notes.) 

"  These  measures  were  faithfully  carried  out,  but  with  no  good  results. 
The  time  having  come  for  another  visit  to  Dr.  Boosa,  the  patient  called  at  my 
office,  when  examination  revealed  fluctuation  at  the  summit  of  the  mastoid 
process,  indicating,  however,  a  small  quantity  of  fluid,  and  attended,  as  it 
seemed  to  me,  with  too  little  pain  to  be  explained  by  the  theory  of  a  perios- 
titis. I  thereupon  advised  him  to  postpone  his  visit  to  New  York,  and  poul- 
tice the  tumor  for  twenty-four  hours,  and  then  report  again.  At  his  next  visit 
I  found  the  swelling  and  fluctuation  slightly  increased,  and  I  freely  incised  the 
integuments  to  the  bone,  liberating  about  half  a  drachm  of  thick,  healthy- 
looking  pus  without  disagreeable  odor.  I  then  probed  the  wound,  expecting 
to  find  denuded  bone,  but  I  failed  to  detect  a  greater  degree  of  roughness  than 
is  peculiar  to  that  portion  of  the  cranium.  I  advised  him  to  keep  the  wound 
open  and  favor  the  discharge  by  poulticing.  The  discharge  for  the  succeeding 
few  days  was  little,  but  resulted  in  a  marked  diminution  of  the  tinnitus  and  a 
corresponding  sense  of  relief  to  the  patient.  He  now  failed  to  report  to  me 
for  about  a  week,  and  meanwhile,  from  lack  of  attention,  the  incision  healed, 
and  when  he  presented  himself  again  there  was  a  re-accumulation  of  pus  in 
much  greater  quantity  than  previously.  This  I  evacuated,  and  found  it  of 
the  same  character  as  before.  Thereafter  the  wound  was  kept  open  and  the 
tinnitus  ceased,  and  the  patient  declared  to  me  and  others  that  he  was  '  a  new 
man.'  From  this  time  my  regular  attendance  ceased  until  May  12, 1870,  when 
I  was  recalled  and  obtained  the  following  history  .  He  had  continued  in  his 
improved  condition  until  the  evening  previous,  which  he  was  passing  in  social 
enjoyment  with  his  family  and  a  brother  who  was  paying  him  a  visit,  and, 
when  laughing  violently  at  some  burst  of  humor,  he  stopped  suddenly  and 
exclaimed  :  '  There,  I  guess  I  have  laughed  too  hard,  for  I  have  made  my  head 
ache.'  No  further  reference  was  made  to  his  suffering  until  he  had  retired  to 
his  room  at  bedtime,  when  he  informed  his  wife  that  he  was  suffering  from  an 
intense  frontal  headache  ;  he  also  complained  of  rigors,  and  passed  an  uneasy, 
sleepless  night.     Notwithstanding  a  resort  to  several   domestic  remedies. 


428  MASTOID   CARIES — CASES. 

May  13,  I  found  the  patient  still  suffering  from  pain  through  the  forehead  and 
temples  ;  pulse  TO,  regular,  and  with  steady  rhythm  ;  tongue  brawny,  a  thin 
white  fur  upon  it ;  intellect  clear ;  skin  unusually  open,  and  feeling  like  the 
third  stage  of  a  paroxysm  of  intermittent  fever,  which  I  confess  1  was  disposed 
to  consider  it,  inasmuch  as  he  had  previously  suffered  from  that  disease.  I 
did  not  consider  the  symptoms  sufficiently  clear  to  indicate  anti-periodic  treat- 
ruent,  aud  I  therefore  temporized  by  giving  the  following  palliative  (a  mixture 
of  rnorph.,  aconite,  and  camphor  water).  May  14th,  found  him  no  better. 
Skin  still  open ;  pulse  68,  with  slight  unsteadiness  of  rhythm,  coating  still 
more  inflammatory  ;  headache  the  same  ;  urine  rather  copious  ;  intellect  in 
the  morning  clear,  but  once  had  requested  an  imaginary  window-frame  to  be 
removed  from  his  bed  ;  pupil  unaffected,  no  intolerance  of  light  or  sound ; 
temper  cheerful.  I  abandoned  the  malarial  theory,  and  expressed  myself  to 
the  friends  as  apprehensive  of  basilar  meningitis,  consecutive  to  subacute 
inflammation  of  the  mastoid  cells.  Ordered  an  active  cathartic,  and  3  ss  bro- 
mide of  potassium,  combined  with  the  iodide.  May  14th,  p.m. — Visited  him 
in  consultation  with  my  partner,  Dr.  D.  H.  Nash.  No  relief;  on  the  contrary, 
an  increase  of  the  cerebral  disturbances,  occasionally  delusions  and  illusions  of 
mind,  and  mostly  of  the  ludicrous  sort ;  pulse  slow  and  somewhat  staggering  ; 
no  pain  in  the  ear  or  its  surroundings  ;  bowels  had  moved  freely  two  or  three 
times ;  urine  still  copious  ;  has  had  no  sleep.  Continue  the  bromide  of  potas- 
sium mixture,  apply  large  blister  to  the  nape  of  the  neck,  and  give  gr.  xx 
hydrate  of  chloral,  and  repeat  in  four  hours  if  necessary.  15th — Had  slept 
about  two  hours ;  general  condition  no  better ;  decidedly  humorous  in  his 
behavior ;  double  vision,  without  apparent  strabismus,  could  not  read ;  pulse 
60,  more  irregular  ;  had  less  pain  in  the  head,  or  at  least  he  said  less  about  it. 
Continued  same  line  of  treatment,  with  addition  of  gr.  ij  calomel  once  in  four 
hours.  Blister  acted  thoroughly.  15th,  P.M. — Condition  little  changed. 
Prognosis  to  family — fatal  result,  qualified  by  suggestion  of  possible  relief 
from  trephining  mastoid  process.  May  16,  a.m. — Patient  worse ;  suggested 
the  counsel  of  Dr.  Eoosa ;  treatment  the  same.  Met  him  at  9  p.m.,  with  Dr. 
Nash.  Agreed  to  diagnosis  of  meningitis,  with  probable  origin  from  mastoid 
cells.  Determined  on  free  explorative  incision  upon  the  mastoid  process,  and 
use  of  trephine  if  developments  indicated  it.  Accordingly  Dr.  Roosa  made  an 
incision  one  inch  and  a  half  long,  parallel  with  the  attachment  of  the  auricle 
(about  one  half-inch  posterior),  down  to  the  bone,  permitting  thorough  exam- 
ination with  the  finger  as  well  as  with  the  probe.  This  means,  however, 
failed  on  the  part  of  either  of  us  to  discover  either  necrosis  or  a  denuded  state 
of  the  bone.  After  a  long  search,  and  when  the  search  and  further  proce- 
dure were  about  to  be  abandoned,  the  probe  (in  the  hands  of  Dr.  Hubbard,  R.) 
— Bowman's  No.  1 — caught  in  a  little  depression,  and  by  considerable  pressure 
passed  the  external  table  of  the  cranium,  into  the  interior  of  the  mastoid  por- 
tion of  the  temporal  bone,  to  .the  depth  of  one  and  a  half  inch,  without  other 
resistance  than  that  afforded  by  the  external  table.  The  orifice  was  now 
enlarged  sufficiently  to  favor  the  escape  of  any  pus  that  might  be  in  the  depths 
of  the  bone,  an  opening  three-eighths  of  an  inch  in  diameter,  but  no  great 
quantity  of  pus  escaped  (just  a  trace,  R.).  Subsequent  examination  with  the 
probe  revealed  a  cavity  of  considerable  size,  caused  by  the  breaking  down  of 


MASTOID  CARIES — CASES.  429 

the  mastoid  cells.  (The  incision  was  carefully  syringed  with  tepid  water,  and 
the  opening  plugged  with  lint,  K.)  17th— I  first  observed  dilatation  of  the 
pupils,  with  gradually  increasing  drowsiness,  attended  by  delirium.  This 
condition  continued,  with  occasional  aggravations,  until  the  19th,  when  the 
patient  passed  slowly  into  a  state  of  profound  coma,  and  he  died  without  con- 
vulsions, at  2  o'clock  a.m.,  May  20.  No  post-mortem  examination  could  be 
obtained." 

I  have  only  to  add  a  few  words  to  the  history  thus  so  graphically  given  by 
Dr.  Hubbard.  On  the  evening  of  the  operation,  or  the  third  and  last  time  I 
saw  the  patient,  I  examined  the  case  as  carefully  as  possible,  and  I  found  the 
membrana  tympani  intact  and  translucent,  no  congestion  whatever.  There 
was  no  bulging  in  any  part  of  its  surface.  The  patient,  who  recognized  me 
perfectly,  and  showed  that  his  memory  was  unimpaired,  heard  my  watch 
about  six  inches  from  the  ear— a  decided  improvement  upon  the  hearing 
power  on  the  two  occasions  when  I  had  previously  seen  him.  There  was 
absolutely  no  tenderness  in  any  part  of  the  mastoid.  Besides  a  very  minute 
opening  near  the  superior  boundary  of  the  process,  which  was  scabbed  over, 
there  seemed  to  me  to  be  no  abnormal  appearance  in  this  part,  and  I  examined 
it  very  carefully.  On  probing  this  minute  opening,  which  was  the  trace  of 
Dr.  Hubbard's  incision  of  some  weeks  before,  there  was  no  escape  of  pus. 

So  doubtful  did  the  case  seem  to  me,  even  with  the  history  of  the  abscesses 
which  had  been  opened,  that  I  hardly  expected  that  the  free  incision  which  I 
made  would  reveal  anything  abnormal. 

There  are  several  points  in  this  case  which  distinguish  it 
from  any  that  I  have  seen,  or  that  I  have  been  able  to  find 
reported. 

I. — There  never  was  a  suppuration  of  the  membrana  tym- 
pani. A  primary  inflammation  of  the  mastoid  cells  or  their 
lining  membrane,  or  of  the  periosteum  in  this  region,  is  very 
rare,  as  is  a  middle  ear  inflammation  in  which  the  mastoid 
becomes  involved,  without  suppuration  in  the  cavity  of  the 
tympanum.  I  have  seen  one  case,  however,  in  which  the  use 
of  the  nasal  douche  caused  an  inflammation  of  the  mastoid 
of  one  side,  without  suppuration  in  any  part  of  the  ear,  while 
in  the  other,  suppuration  of  the  membrana  tympani  occurred. 
But  the  mastoid  inflammation  was  quickly  overcome  by  the 
use  of  leeches. 

II. — Until  the  formation  of  the  abscess,  there  were  no 
marked  symptoms  indicating  the  true  seat  of  the  disease. 
The  symptoms  were  rather  those  of  a  chronic  inflammation 
of  the  middle  ear,  that  is  to  say,  tinnitus,  fulness,  and  occa- 
sionally slight  pain.     Certain  it  is,  there  was  none  of  the 


430  MASTOID  CAEEES — CASES. 

agonizing  distracting  pain  of  which  patients  with  periostitis 
usually  complain. 

III! — The  interval  of  apparent  recovery  after  the  evacua- 
tion of  the  pus. 

In  reviewing  the  case,  the  conclusion  seems  to  me  inevita- 
ble that  we  had  from  the  beginning  to  do  with  a  subacute 
inflammation  of  the  mastoid  portion  of  the  middle  ear,  and 
which  smouldered  until  the  blazing  up  in  the  abscess  opened 
by  Dr.  Hubbard.  The  origin  of  this  was,  of  course,  the  coryza, 
or  cold  in  the  head.  It  was  perhaps  an  inflammation  of  the 
mastoid  and  tympanic  cavity  which  extended  less  rapidly  than 
usual  to  the  periosteum  and  tissues  lying  upon  it,  and  it  was 
on  this  account  a  concealed  and  dangerous  foe.  According 
to  a  theory  of  mine  the  second  attack  was  essentially  a  new 
process  attacking  the  former  seat  of  disease,  or  locus  minoris 
resistentice — "  the  weak  spot,"  as  patients  say,  induced  by  some 
exciting  cause  that  is  unknown.  The  integrity  of  the  nerve, 
up  to  a  late  period,  is  shown  by  the  amount  of  hearing  power 
exhibited  on  the  evening  that  the  perforation  of  the  bone  was 
made. 

Dr.  C.  R.  Agnew  reports  a  case  which  has  been  alluded  to 
in  the  account  of  caries  of  the  mastoid,  an  outline  of  which, 
made  up  from  Dr.  Agnew's  report,  is  herewith  presented. 

Case  III. — Acute  Otitis  Media — Mastoid  Periostitis — Opening  of  Mastoid  by 
a  Gimlet — Subsequent  Trephining — Hyperostosis  of  Mastoid  Cells — Re- 
covery. 

Miss  X,  in  middle  life,  caught  cold  and  a  sore  throat,  after  exposure  in  the 
country  on  the  26th  of  August,  1854.  Immediately  after  she  was  seized  with 
violent  pain  in  the  right  side  of  the  head  and  corresponding  ear.  On  Septem- 
ber 5,  a  swelling  began  in  the  mastoid  region,  the  severe  pain  from  the  ear 
having  continued  until  that  time.  On  the  30th  of  September,  the  pain  ex- 
tended rather  suddenly  down  behind  the  course  of  the  sterno-cleido-mastoid 
muscle.  On  the  2d  of  October,  an  incision  was  made  over  the  mastoid,  and  it 
was  perforated  by  means  of  a  gimlet.  Pus  followed  the  incision  through  the 
periosteum,  and  also  on  the  withdrawal  of  the  gimlet.  Dr.  Agnew  first  saw 
the  case  a  year  after  this,  when  there  was  considerable  swelling  of  the  auditory 
canal.  The  concha  and  mastoid  region  was  tender  to  the  touch,  and  over  the 
center  of  the  mastoid  was  a  small  fistulous  opening  which  passed  into  a  narrow 
sinus,  running  through  the  bone  towards  the  tympanic  cavity.  This  sinus 
was  with  difficulty  entered  by  a  No.  4  Bowman's  probe.  The  principal  sub- 
jective symptoms  were  pain  in  the  temporal  bone,  apprehension  of  brain  dis- 


MASTOID   CARIES — CASES.  431 

ease,  slight  loss  of  memory,  nervousness,  and  wakefulness.  The  face  was 
anxious ;  the  operation  was  advised,  hut  it  was  declined. 

In  February,  1870,  the  patient  had  an  alarming  attack.  The  principal 
symptoms  were  a  feeling  of  "  general  agony,"  and  paralysis  of  the  right  7th 
nerve,  with  obstinate  vomiting.  This  was  on  Friday,  and  on  the  Wednesday 
following,  the  paresis  had  disappeared,  but  there  was  some  loss  of  memory 
and  a  slight  degree  of  aphasia. 

On  February  21,  1870,  Dr.  Agnew  "  proceeded  to  trephine  the  mastoid 
through  a  sweeping  cut,  using  for  the  purpose  a  half-inch  instrument  (trephine) 
with  the  pin  in  the  mouth  of  the  sinus,"  a  dense  button  of  bone  nearly  three- 
eighths  of  an  inch  thick.  Dr.  Agnew  believes  that  the  cells  were  filled  by  a 
dense  bony  growth.  Drs.  Van  Buren,  Loring,  Keyes,  and  myself  were  present 
at  the  operation.  The  sinus  was  enlarged  by  using  a  triangular  steel  bit,  so 
that  the  entire  depth  of  the  track  opened  was  about  five-eighths  of  an  inch. 
No  pus  was  found  ;  no  caries  of  the  bone.  The  patient  experienced  a  marked 
amelioration  of  her  symptoms  after  the  operation,  and,  as  Dr.  Agnew  informs 
me,  continues  well  at  this  time,  now  three  years  since  the  operation. 

Dr.  D.  E.  Ambrose,  formerly  house-surgeon  to  the  Man- 
hattan Eye  and  Ear  Hospital,  lately  trephined  the  mastoid 
process,  in  a  case  of  peculiar  interest,  the  notes  of  which  the 
Doctor  has  given  me,  besides  allowing  me  to  see  the  patient. 

Case  IV. — Mastoid  Periostitis — Abscess — Incision — Polypoid  Groicths  from 
Wound — Trephining — Bone  found  very  dense — Removal  of  Plug  one  inch 
long — Recovery. 

"  Bliss  S.  C,  age  19,  came  under  observation  February  15, 1872,  complaining 
of  deafness  in  right  ear,  and  stated  that  about  four  years  ago  she  had  an 
attack  of  severe  pain  in  that  ear,  accompanied  with  slight  hemorrhage,  and 
followed  by  discharge  of  pus.  H.  D.  R.  E.,  watch  pressed  upon  auricle.  Voice 
in  very  loud  tone  about  six  inches  from  the  ear.  There  was  a  small  quantity 
of  cerumen  adhering  to  the  wall  of  canal.  The  membrana  tympani  was 
clearly  visible,  but  showed  evidences  of  previous  trouble.  Right  Eustachian 
tube  closed,  and  impervious  to  Politzer's  method  or  the  catheter,  after  fre- 
quent local  applications  of  nitrate  of  silver. 

"  Left  ear  normal. 

"  The  small  quantity  of  wax  having  been  removed,  treatment  by  electricity 
was  commenced  and  continued  three  times  a  week  for  about  six  weeks,  at  the 
expiration  of  which  time  H.  D.  R.  E. ;  voice,  in  tone  of  ordinary  conversation, 
distinctly  heard  at  fifteen  feet.  This  gave  great  satisfaction,  as  she  had  been 
much  disheartened  by  prospect  of  complete  and  permanent  deafness  of  that  ear. 
Patient  was  now  discharged. 

"  On  20th  of  April,  1872,  she  had  an  acute  attack  of  periostitis  in  external 
auditory  canal,  which  involved  the  mastoid  cells,  and  in  spite  of  leeches,  warm- 
water  douches,  and  incision  down  to  the  bone  of  the  canal,  resulted  in  abscess 
of  mastoid  cells. 


432  MASTOID  HYPEROSTOSIS — CASE. 

"  The  abscess  protruded  through  the  posterior  wall  of  canal,  and,  on  being 
opened  with  a  bistoury,  discharged  a  considerable  quantity  of  pus. 

"  The  .ear  was  now  frequently  cleansed  with  lukewarm  water ;  but,  not- 
withstaudiug  this,  there  soon  sprang  from  the  mouth  of  the  abscess  polypoid 
growths,  which  astringents,  including  the  solid  stick  of  nitrate  of  silver,  and 
several  excisions,  failed  to  subdue.  There  still  remained  a  constant  aching, 
with,  occasionally,  sharp  darting  pains  in  mastoid  process,  which  radiated  to 
different  quarters  of  temporal  region.  On  two  occasions  patient  found  small, 
thin  scales  of  bone  in  the  purulent  discharge.  I  then  passed  a  silver  probe, 
bent,  through  the  opening  of  the  abscess,  and  could  distinctly  detect  dead 
bone,  both  in  posterior  and  superior  portions  of  mastoid  cells.  The  end  of  the 
probe  was  blackened  with  sulphur  or  phosphorus.  I  was  very  careful  not  to 
push  the  probe  beyond  the  level  of  the  mouth  of  the  abscess,  lest  I  should  do 
irreparable  damage  to  the  labyrinth  wall,  and  not  too  far  behind  or  above, 
for  fear  that  in  the  former  direction  I  should  encroach  upon  the  transverse 
sinus,  and  in  the  latter  push  through  to  the  dura  mater.  Meanwhile  the  mas- 
toid process,  at  its  lower  portion,  became  red,  slightly  swollen,  and  very  tender 
to  the  touch. 

"  After  patient  and  persevering  efforts  to  effect  a  cure  by  keeping  the  ear 
cleansed  as  thoroughly  as  possible,  and  by  taking  tonics  and  nutritious  diet  for 
sis  weeks  without  any  substantial  improvement,  I  resolved  upon  trephining, 
lest  by  further  delay  the  inflammatory  action  should  extend  to  deeper  and 
more  important  parts,  and  hopelessly  destroy  her  power  of  hearing  in  that  ear, 
if  not  terminate  her  life. 

"  On  the  1st  of  June,  1872,  after  making  an  incision  two  inches  and  a  half 
long,  down  to  the  bone,  parallel  with  the  auricle,  and  half  an  inch  from  its 
attachment,  I  separated  the  periosteum  from  the  bone  to  an  extent  sufficient  to 
admit  a  quarter-inch  trephine,  and  inserted  that  instrument  on  a  line  with 
superior  border  of  external  meatus,  and  about  half  an  inch  from  the  attach- 
ment of  the  auricle,  directing  the  instrument  slightly  forward  in  a  horizontal 
position.  After  the  trephine  had  penetrated  to  the  depth  of  half  an  inch,  and 
finding  myself  on  just  as  firm  bone  as  at  the  commencement,  I  heartily  wished 
the  affair  was  over  with ;  but  remembering  that  Troltsch  says  that  'the  depth 
to  which  we  must  go  is  sometimes  very  considerable,'  I  regained  my  courage 
and  persevered  with  the  operation  until  I  felt  a  slight  yielding  beneath  the 
instrument.  I  immediately  withdrew  it  and  tried,  with  moderate  force,  to 
extract  the  plug  of  bone  with  bone  forceps,  to  which,  however,  it  did  not  yield 
in  the  slightest  degree.  Again  the  trephine  was  replaced,  and,  after  a  few 
more  gentle  turns,  there  was  a  very  perceptible  sensation  of  further  yielding 
beneath  the  instrument ;  and  a  second  time  the  trephine  was  withdrawn  and 
a  second  ineffectual  effort  made  to  extract  the  plug,  though  it  yielded  slightly 
to  lateral  pressure.  The  trephining  was  again  renewed,  and,  after  a  few  gentle 
turns,  withdrawn  ;  and  now  the  plug  was  easily  extracted.  The  instrument 
was  repeatedly  withdrawn  and  very  lightly  worked  after  the  first  yielding  was 
detected,  lest  by  a  suddeu  giving  way  of  parts  beneath,  it  should  be  suddenly 
plunged  into  the  mastoid  cells,  and,  in  a  moment,  defeat  all  my  hopes  from 
the  operation.  The  plug  having  been  withdrawn,  I  was  surprised  at  the  small 
amount  of  pus  that  escaped,  for  this,  together  with  the  bone  dust,  certainly  did 


MASTOID   HYPEROSTOSIS — CASE.  433 

not  exceed  one  drachm.  This  led  me  to  suspect  that  I  had  not  entered  the 
mastoid  cavity  at  all ;  and  to  remove  all  doubts  upon  this  point,  I  passed  a  bent 
probe  through  the>opening  of  the  abscess,  and  another  through  the  wound 
just  made,  and  could  distinctly  touch  and  move  the  one  with  the  other. 

"  The  wound  was  then  syringed  with  warm  water,  to  which  was  added  a 
few  drops  of  carbolic  acid,  and  then  plugged  with  lint,  which  treatment  was 
continued  daily,  and  sometimes  twice  a  day,  for  six  weeks,  when  the  wound 
completely  healed,  without  any  discharge  from  the  ear,  and  without  a  single ' 
uncomfortable  sensation  remaining.  The  constant  aching  and  frequent  dart- 
ing pains  with  which  the  patient  had  been  so  long  harassed  were  almost 
instantly  relieved  ;  for  the  next  day,  after  all  effects  of  anaesthetic  had  passed 
off,  she  complained  of  nothing  but  the  soreness  of  the  wound,  nor  did  she  com- 
plain of  anything  more  from  that  day  throughout  the  entire  healing  process. 
The  polypoid  growths  also,  which  had  resisted  all  other  measures  that  I 
had  used,  ceased,  in  a  few  days,  to  grow,  and  soon  entirely  disappeared,  with- 
out any  additional  treatment  than  simply  cleansing  the  ear.  This  was  appa- 
rently a  perfect  cure  until  four  weeks  after  the  wound  had  healed — ten  weeks 
from  the  date  of  the  operation — when,  after  exposure  to  a  draught  of  damp 
air,  she  was  suddenly  seized  with  sharp  pain  in  the  same  ear,  which  was  soon 
followed  by  a  throbbing  sensation. 

"  Examination  revealed  inflammatory  action  only  on  anterior  and  inferior 
walls  of  canal.  The  application  of  mild  current  of  electricity  would  relieve  all 
pain  within  ten  minutes,  while  a  strong  current  aggravated  it.  But  the  pain 
would  return  again  during  the  night,  and  sometimes  within  an  hour  after  the 
application.  Injections  of  warm  water  were  then  substituted  with  similar 
results,  and  patient  was  put  on  quinine  and  iron,  and  five  grains  of  iod.  potass, 
three  times  per  day.  These  attacks  of  aching  and  darting  pains  became  of  very 
frequent  occurrence — every  two  or  three  days,  and  sometimes  as  often  during 
twenty-four  hours — with  an  occasional  discharge  of  a  few  drops  of  blood  from 
the  ear.  Upon  the  superior  wall  of  external  canal  there  is  a  hard  bony  sub- 
stance, almost  invariably  covered  with  a  purulo-gelatinous  material,  a  little  of 
which,  on  the  end  of  the  probe,  emits  a  very  offensive  cadaverous  odor.  This 
part  is  very  tender  when  pressed  upon  by  the  probe. 

"  H.  D.  R.  E.  Voice  slightly  raised  above  ordinary  conversation  heard  dis- 
tinctly at  fifteen  feet. 

"March  17th,  1873. — I  induced  the  patient  to  go  to  the  Manhattan  Eye  and 
Ear  Hospital,  to  get  the  advice  of  Dr.  Roosa." 

I  found  the  patient  in  a  comparatively  comfortable  condi- 
tion, able  to  pursue  her  ordinary  avocation,  and  it  seemed  to 
me  that  there  was  an  exostosis  of  the  osseous  canal,  and  per- 
haps of  the  tympanic  cavity,  and  that  the  pain  was  due  to 
periostitis.  I  advised  the  use  of  iodide  of  potassium  and  the 
continuation  of  the  warm  douche.  The  process  of  sclerosis 
of  the  osseous  structure  is  probably  going  on.  The  change  in 
the  bone  is  similar  to  that  which  occurred  in  the  preceding  case. 
28 


434  CAEIES  AND  NECEOSIS. 

CARIES  AND  NECROSIS  OF  THE  TEMPORAL  BONE. 

The  surgeon  is  often  baffled  in  his  efforts  to  check  a  dis- 
charge of  pus  from  the  ear,  because  it  comes  from  a  part  of 
the  bone  that  has  been  softened  by  a  carious  process.  It  is 
not  always  possible  to  positively  decide  that  the  bone  is  in 
this  condition,  for  the  part  thus  affected  may  be  sufficient  to 
maintain  a  suppurative  process,  and  yet  be  very  small  and 
hidden  from  view.  Even  the  proper  use  of  a  probe  in  a  dis- 
eased cavity  of  the  tympanum,  in  order  to  enable  us  to  decide 
as  to  the  existence  of  caries,  is  a  delicate  matter,  and  should  be 
undertaken  with  care,  lest  important  parts  be  penetrated.  The 
careful  surgeon  is,  therefore,  often  in  doubt  as  to  how  much 
of  the  bone  may  be  invaded,  even  when  he  finds  a  superficial 
point  that  gives  evidence  of  disease.  The  probe  cannot  be 
used  in  the  ear  as  a  diagnostic  means,  with  that  freedom  that 
it  is  employed  in  solid  parts  that  have  no  such  important  and 
delicate  surroundings. 

All  parts  of  the  temporal  bone  may  become  carious  as 
the  result  of  a  chronic  suppurative  process.  The  osseous  por- 
tion of  the  auditory  canal  is  one  of  the  favorite  positions  for 
such  a  morbid  change.  The  upper  wall  of  this  canal  is  but  a 
short  distance  from  the  dura  mater  and  the  cerebrum,  and 
we  have  already  discussed  the  relations  of  the  mastoid  cells 
to  the  lateral  sinus.  Thus  we  may  have  inflammation  of 
the  brain  and  affections  of  the  venous  circulation,  even  when 
the  caries  is  confined  to  the  external  ear.  It  is  probable, 
however,  that  caries  of  the  auditory  canal  is  usually  the  result 
of  a  chronic  suppuration  of  the  middle  ear,  and  not  of  a 
primary  and  independent  affection  of  the  peripheral  portion. 
The  anatomical  relations  of  the  cavity  of  the  tympanum,  than 
which  there  are  none  more  important  in  the  whole  system, 
necessarily  involve  serious  consequences  from  caries  of  any 
part  of  its  walls.  These  consequences  also  necessarily  include 
great  impairment  of  the  hearing,  while  we  may  have  menin- 
gitis, cerebral  abscess,  pyaemia,  paralysis,  or  fatal  hemorrhage. 
Indeed,  in  the  treatment  of  any  of  these  consequences  of  a 
chronic  suppuration,  we  are  always  treading  upon  dangerous 
ground,  which  may  break  under  our  feet  at  any  moment.     In 


CARIES  AND  NECROSIS.  435 

some  fortunate  cases,  however,  none  of  these  unpleasant  results, 
except  the  loss  of  hearing,  occur ;  the  diseased  bone  is  thrown 
off,  and  the  parts  heal.  Nearly  the  whole  of  the  temporal 
bone  may  be  cast  off  in  this  manner  without  involving  the  life 
of  the  patient. 

It  has  already  been  seen  that  the  ossicula  auditus  may 
become  carious  and  lost  in  the  course  of  an  acute  suppuration. 
The  same  thing  may  occur  in  the  course  of  a  very  chronic 
process,  and  small  points  of  dead  bone  are  frequently  found 
when  the  cavity  of  the  tympanum  has  been  for  a  long  time 
exposed  from  a  loss  of  the  membrana  tympani.  It  is  shown, 
however,  by  Case  II.,  page  426,  occurring  in  my  practice,  that 
caries  may  occur  with  an  intact  drum-head.  Dr.  Orne  Green* 
has  also  published  a  report  of  a  post-mortem  examination, 
that  illustrates  the  same  fact.  Dr.  Geo.  E.  Francis,  of  Wor- 
cester, made  the  autopsy. 

A  man  twenty-five  years  of  age,  who  was  subject  to 
catarrh,  had  had  a  discharge  from  his  ear  for  two  years  ; 
at  times  acute  symptoms  occurred.  Two  months  before 
death  he  could  not  hear  conversation.  He  also  had  cerebral 
symptoms,  dizziness,  headache,  double  vision,  and  partial 
paralysis,  but  of  what  regions  is  unknown.  He  died  coma- 
tose, and  at  the  autopsy  a  collection  of  pus  was  found  in  the 
brain,  just  over  a  carious  spot  communicating  with  the  tym- 
panic cavity.     The  pus  lay  directly  upon  the  bone. 

Dr.  Green  examined  the  bone,  and  found  a  sinus  through 
the  upper  osseous  wall  of  the  auditory  canal,  just  above  and 
external  to  the  small  process  of  the  malleus.  The  point  of  an 
ordinary  probe  could  be  inserted  in  this  opening,  and  it  com- 
municated with  the  auditory  canal  and  the  small  cavity  in 
front  of  the  handle  of  the  malleus.  From  this  cavity  it  passed 
backwards  and  inwards  into  a  circular  cavity  about  one-quar- 
ter of  an  inch  in  diameter  in  the  cancellated  structure  of  the 
bone.  The  roof  of  bone  over  this  cavity  had  entirely  disap- 
peared, so  that  there  was  a  direct  communication  with  the 
brain.  All  the  walls  of  this  space  were  irregular  and  carious. 
"  The  membrana  tympani  was  entire  and  apparently  healthy,  and 

*  Transactions  of  the  American  Otological  Society,  1871. 


436 


CARIES  AND  NECROSIS. 


of  normal  transparency  and  thickness  in  every  part  below  the 
small  process  of  the  malleus  honey 

The  head  of  the  malleus  and  the  whole  of  the  incus  were 
wanting,  but  it  could  not  be  positively  stated,  that  they  were 
not  removed  during  the  dissection.  They  must  certainly  have 
been  in  a  softened,  diseased  condition,  or  they  would  not  have 
escaped  so  readily.  Von  Troltsch  reported  a  similar  case  to 
this,  and  called  attention  to  the  little  cavity,  which  is  a  part 
of  the  tympanic  cavity,  and  is  situated  just  above  and  external 
to  the  head  of  the  malleus.  In  a  normal  condition,  it  is  sepa- 
rated from  the  auditory  canal  by  an  extremely  thin  layer  of 
bone.  Yon  Troltsch  dissected  a  specimen  in  which  he  found 
a  polypoid  growth  springing  from  this  point  and  projecting 
into  the  canal. 

Dr.  O.  D.  Pomeroj-*  has  reported  a  case  of  exfoliation  of 
the  whole  of  the  temporal  bone,  except  the  lower  part  of  the 
external  auditory  canal  and  the  inner  part  of  the  petrous  por- 
tion.   The  patient  recovered,  of  course  with  loss  of  hearing  and 


Fig.  83. 


Fig 


Two  Views  of  Temporal  Bone  exfoliated  in  the  covrse  of  Chronic  Suppuration.    From 
Dr.  Ponierot/s  Collection. 

facial  paralysis.     The  patient  was  a  boy  aged  twenty  months, 
and  had  a  discharge  from  the  ear,  accompanied  by  severe 


*  Transactions  American  Otological  Society,  1872. 


CAEIES  AND  NECROSIS.  437 

pain  for  three  months  beforo  Dr.  Pomeroy  saw  him.  There 
was  mastoid  periostitis,  and  an  incision  was  made.  Two  days 
after  another  was  made,  and  the  bone  was  found  uneven  and 
rough,  and  there  was  a  fistula  leading  into  the  mastoid  cells. 
For  three  months  after,  the  child  did  moderately  well,  although 
there  remained  considerable  swelling  in  front  of  the  auricle. 
At  the  end  of  this  period,  a  small  piece  of  dead  bone  was 
observed  behind  and  a  little  above  the  external  auditory  canal, 
and  in  about  a  month  afterwards  it  became  movable,  and  was 
grasped  by  forceps  and  some  traction  was  made  upon  it,  but 
so  much  hemorrhage  was  caused  that  the  attempt  to  remove 
the  dead  bone  was  given  up.  In  about  six  weeks  the  mother 
brought  the  child  to  the  Manhattan  Eye  and  Ear  Hospital, 
and  also  the  dead  bone  that  is  represented  in  the  accompany- 
ing engravings,  which  were  made  from  a  photograph  prepared 
under  the  direction  of  Dr.  Pomeroy. 

Six  months  after  the  child  was  doing  well.  The  aperture 
through  which  the  sequestrum  passed  had  closed.  The  dis- 
charge of  pus  was  moderate  and  the  general  health  of  the  child 
was  good. 

"Wilde,*  Agnew,t  Gruber,|  and  Voltolini§  have  reported 
cases  of  the  extraction  through  the  external  meatus  of  the  whole 
of  the  internal  ear,  during  the  life  of  the  patient.  Wilde's  case 
occurred  in  the  practice  of  Sir  Philip  Crampton.  The  patient 
was  a  young  lady,  who,  after  the  most  urgent  symptoms  of 
inflammation  of  the  brain,  with  paralysis  of  the  face,  arm  and 
leg,  and  total  loss  of  hearing  of  one  side,  recovered  from 
the  head  symptoms  and  paralysis  of  the  extremities  after  a 
copious  discharge  of  pus  from  the  ear.  "  One  day  Sir  Philip 
perceiving  a  portion  of  loose  bone  lying  deep  in  the  cavity 
of  the  meatus,  drew  out  the  whole  of  the  cochlea  and  semi- 
circular canals." 

Dr.  Agnew's  case  occurred  in  a  patient  who  suffered  from 
exostosis  consequent  upon  chronic  suppuration  of  the  oppo- 
site ear,  and  who  afterward  died  of  brain  disease  dependent 

*  Test-Book,  p.  37. 

f  Von  Troltsch  on  the  Ear,  American  Edition, 

%  Lehrbuch,  p.  542. 

§  Monatsschrift  fur  Qhrenheilkunde,  Janrgang  IV.,  p.  84. 


438  NECKOSIS  OF  INTEENAL  EAE. 

upon  retention  of  pus  by  the  exostosis.  The  case  as  regards 
the  exostosis  will  be  found  on  page  404  of  this  work. 

The  patient  was  a  gentleman  of  thirty-eight  years  of  age,* 
who  had  suffered  from  chronic  suppurative  inflammation  of 
the  middle  ear  for  the  greater  part  of  thirty-two  years.  Three 
years  before  the  patient  came  under  Dr.  Agnew's  observation, 
after  a  severe  exacerbation  of  the  aural  inflammation,  com- 
plete loss  of  hearing  occurred  in  the  ear,  and  paralysis  of  the 
facial  nerve  of  that  side.  Granulations  continued  to  recur 
constantly.  On  the  16th  of  April,  1862,  the  patient  was  in  a 
deplorable  condition ;  he  had  suffered  for  months  from  pain 
in  the  ear,  loss  of  sleep,  loss  of  appetite  and  dizziness.  The 
concha  was  swelled  and  extremely  tender;  a  pear-shaped 
polypus,  of  fibrous  character,  which  was  kept  bathed  in  very 
fetid  pus,  projected  from  the  meatus.  Dr.  Agnew  placed  the 
patient  under  the  influence  of  chloroform,  and  removed  the 
polypoid  mass  by  means  of  Wilde's  snare.  In  attempting  to 
get  the  snare  about  the  base  of  the  polypus,  he  encountered 
a  solid  body  in  the  middle  ear,  which  proved  to  be  the  ne- 
crosed internal  ear.  An  incision  was  then  made  into  the  audi- 
tory canal,  in  order  to  enable  the  forceps  to  grasp  the  seques- 
trum. Dr.  Agnew's  report  says :  "  Having  got  the  body  in 
the  grasp  of  the  forceps,  a  slight  rocking  motion,  with  trac- 
tion, enabled  me  to  extract  it."  The  whole  of  the  internal  ear 
— vestibule,  semicircular  canal,  and  cochlea — were  found  to  be 
removed."  This  patient  lived  four  years  after  this,  and  never 
had  any  painful  symptoms  from  that  side  of  the  head  after- 
ward. 

Gruber's  case  occurred  in  a  child  thirteen  years  of  age. 
Both  cochleae  were  exfoliated,  and  yet  the  patient  recovered, 
with  no  facial  paralysis — an  evidence  that  the  cavity  of  the 
tympanum  was  left  in  a  comparatively  sound  condition. 

Voltolini'sf  case  was  one  that  occurred  in  the  practice  of 
Dr.  A.  Jacobi,  of  Berlin.  The  whole  labyrinth  was  removed 
from  the  ear  of  a  child  that  is  still  living.  The  substance  of 
the  cochlea  was  not  fully  united  with  the  surrounding  bony 
substance  of  the  petrous  bone,  which,  as  Yoltolini  remarks,  is 

*  American  Medical  Times,  vol.  vi. ,  p.  1 83. 

f  Monatsschrift  for  Ohrenheilkunde,  Jahrgang  IV.,  p.  84. 


CABLES   AND  NECROSIS. 


439 


evidence  that  the  disease  dates  back  to  an  early  period  in  the 
life  of  the  child. 

Toynbee*  reported  four  cases  of  necrosis  of  the  cochlea 
and  vestibule,  in  which  the  parts  had  been  exfoliated  during 
life.  One  of  them  is  Wilde's  case,  already  quoted.  The  pa- 
tients were  adults,  with  the  exception  of  one,  a  child  of  seven 
years  old. 

The  following  engravings  illustrate  the  ravages  which 
chronic  suppuration  makes  upon  the  bony  tissue  of  the  ear. 
They  were  made  from  photographs  of  the  bones,  and  are  from 
the  collection  of  Dr.  0.  E.  Hackley,  who  kindly  allowed  this 
use  of  them. 


Fig.  85. 


Fig.  86. 


Left  Temporal  Bone,  from  Case  I. 

Exterior  view,  showing  the  external  meatus, 
a,,  from  which  the  anterior  wall  has  been 
removed,  as  has  also  the  inner  wall  of  the 
middle  ear.    b.  The  mastoid  process. 


Inner  Surface  of  the  same  Specimen,  showing 

c.  The  vestibule,  d,  d.  The  windings  of  the 
cochlea,  which  have  been  exposed  by  saw- 
ing away  piortion  of  the  bone.  e.  The 
tympanum,  communicating  with  f,  the 
mastoid  cells,  which  have  been  exposed 
by  chipping  away  a  thin  layer  of  bone. 


History. — Case  I.  (Figs.  85  and  86). — Left  temporal  bone 
from  a  man  who  had  phthisis,  and  died  suddenly  of  pneumo- 
thorax, August,  1866.  His  hearing  distance  was  nothing  for 
the  watch,  nor  could  he  distinguish  words,  though  he  seemed 


*  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  113. 


440 


CARIES   OF  TEMPORAL  BONE. 


to  hear  the  sound  of  the  voice.  He  was  very  much  debilitated 
when  he  entered  the  New  York  Hospital,  consequently  no 
thorough  examination  was  made  of  his  ears.  He  had  profuse 
discharge  from  both  ears,  and  polypi  on  both  sides.  On  the  left 
side,  the  post-mortem  examination  showed  polypus  attached 
in  the  middle  ear  and  extending  forwards  into  the  meatus,  and 
backwards  into  the  mastoid  cells ;  membrana  tympani  gone ; 
stapes  only  one  of  ossicles  present;  membrane  of  fenestra 
rotunda  gone. 

Fro.  87. 


Left  Temporal  Bone,  sawed  through  External  Meatus,  Middle  Ear,  and  Cochlea. 

The  pieces  are  turned  to  one  side,  showing — a.  Mastoid  process,  b,  b.  External  meatus,  ending 
in  c,  the  middle  ear.  At  d  there  was  an  opening  downwards  through  the  bony  meatus,  and 
at  e  an  opening  upwards,  by  which  there  was  a  free  communication  with  f,  the  mastoid 
cells,  which  were  separated  from  the  interior  of  the  cranium  by  a  very  thin  layer  of  bone  at 
g.    h,  h,  show  the  cochlea  sawed  through. 

Case  II.  (Fig.  87). — Left  temporal  bone  from  ,  who 

entered  the  New  York  Hospital  August,  1866,  with  great  fever 
and  pain  in  the  left  ear  ;  had  been  sick  two  days.  His  disease 
ran  much  the  course  of  typhoid  fever,  without  marked  head 
symptoms  other  than  the  acute  pain  in  the  ear  (which  only 
existed  the  first  two  days).  "When  a  child  he  had  discharge 
from  the  ear  and  post-anral  abscess  and  disease  of  mastoid 
process. 

On  the  autopsy,  pus  was  found  under  the  dura  mater  and 
in  mastoid  cells ;  the  whole  temporal  bone  was  gone  from  the 
infiltration  of  pus  through  it ;  the  membrana  tympani  was 
completely  destroyed ;  the  base  of  the  stapes  was  the  only 


CAEIES  OF  TEMPOKAL  BONE. 


441 


part  of  the  ossicula  remaining  ;  there  was  an  opening  from  the 
outer  part  of  the  bony  meatus  upwards  into  a  cavity  which 
also  had  an  opening  outwardly. 


Fia.  88. 


'  12 


Bight  Temporal-  Bone,  from  Case  V-,  showing  the  Cranial  Surface  of  the  Bone. 

At  a  the  bone  was  very  thin,  and  broke  away  ivhen  the  dura  mater  was  removed  ;  the  bone  was 
much  hollowed  out  about  b,  the  middle  ear. 

Case  V.  (Fig.  88).— August  18, 1868.— H.  O.  applied  at  New 
York  Eye  and  Ear  Infirmary,  on  account  of  pain  in  right  ear, 
saying  he  had  a  "  kernel "  (wax  ?)  removed  from  his  ear  two 
years  previously,  by  one  of  the  surgeons  of  that  institution. 
The  right  membrana  tympani  was  found  injected,  right  Eu- 
stachian tube  obstructed.  H.  D. — Right  ear,  pressed  ;  Left, 
^|.  Applications  of  warm  water,  with  occasional  leeching, 
were  ordered.  After  some  time  the  walls  of  the  meatus 
swelled  so  that  the  walls  of  the  membrana  tympani  could 
not  be  seen.  Under  varying  treatment  the  state  of  the  case 
was  sometimes  better,  sometimes  worse,  till  March,  1869. 
During  his  attendance  the  patient  twice  stopped  coming, 
thinking  he  was  well,  when  he  complained  of  pain  over  the 
right  side  of  the  head,  starting  from  the  ear.  Expecting 
meningitis,  he  was  taken  as  an  in-patient  at  the  Infirmary, 
April  1st,  1869,  treated  again  with  leeches,  cold  to  head,  bro- 
mide of  potash,  and  tonics.  About  May  1st,  1869,  he  showed 
occasional  delirium,  and  contraction  of  the  muscles  of  the 
nape  of  the  neck  ;  had  retention  of  urine ;  pulse  110-130 ; 
temperature  102°.  Died  May  10th.  No  discharge  from  ear 
for  thirty-six  hours  preceding  death.  On  autopsy,  twelve 
hours  after  death,  we  found  the  brain  slightly  congested  ;  the 
right  optic  nerve  (which  went  to  an  atrophied  eye)  was  atro- 


442  CAEIES  AND  NECROSIS — PROGNOSIS. 

pliied  both  before  and  behind  commissure  ;  the  meninges  of  the 
base  of  the  cerebellum,  and  upper  part  of  the  spiual  cord,  were 
covered  with  lynrph  and  bathed  in  sero-pus  (about  two  oz.) ; 
right  auditory  nerve  very  red ;  periosteum  over  the  posterior 
part  of  the  right  temporal  bone  was  very  easily  detached ;  the 
bone  under  it  was  greenish,  infiltrated  with  pus  ;  the  passage 
from  the  middle  ear  to  the  mastoid  cells  was  much  enlarged, 
with  only  a  thin  wall  of  bone  between  it  and  the  brain.  On 
detaching  the  pericranium  this  wall  was  broken  through. 
Membrana  tympani  entirely  gone  ;  the  promontory  was  rough- 
ened ;  the  stapes  was  the  only  one  of  the  ossicles  left  in 
position. 

Prognosis. — The  prognosis  of  caries  and  necrosis  of  the 
temporal  bone  depends  upon  several  factors.  To  a  marked  de- 
gree it  is  influenced  by  the  age  of  the  patient.  Young  children 
will  throw  off  quite  large  portions  of  the  bone,  and  yet  come 
off  with  their  lives,  while  older  persons  will  usually  succumb  to 
one  of  the  many  consequences,  such  as  pyaemia,  hemorrhage, 
abscess,  which  may  result  from  death  of  bone  in  this  part  of 
the  body.  The  situation  also  of  the  dead  bone  will  influence 
the  prognosis  of  caries  to  a  marked  degree.  Caries  of  the 
mastoid,  especially  when  occurring  in  young  children,  is  very 
often  recovered  from.  Caries  and  necrosis  of  the  walls  of  the 
middle  ear  is  of  course  the  most  dangerous  of  all  that  may 
occur,  especially  caries  of  the  upper  and  lower  wall.  It  has 
been  seen  that  the  whole  internal  or  labyrinth  wall  may  be 
destroyed,  and  the  contents  of  the  external  ear  be  exfoliated, 
and  yet  the  patient  recover.  In  these  cases  the  necrosed 
internal  ear  seems  to  have  passed  through  a  sound  tympanic 
cavity. 

The  prognosis  of  caries  and  necrosis  of  the  temporal  bone 
is,  however,  always  grave  under  any  circumstances,  and  no 
life  can  be  said  to  be  what  the  life  insurance  companies  call  a 
good  risk,  if  a  chronic  suppurative  process  has  gone  on  to  this 
extent.  The  ossicula  auditus  may  be  thrown  off  with  com- 
parative impunity,  as  we  see  by  cases  all  about  us ;  yet 
even  these  cases,  unless  the  suppuration  has  entirely  ceased, 
belong   to  a  class  of  cases  whose   results  we  must  always 


CAEIES  AND  NECROSIS — TREATMENT.  443 

stand  in  dread.  Until  the  parts  have  healed,  and  some  kind 
of  a  neo-plastic  membrana  tympani  has  formed,  we  are  not 
safe  in  giving  a  decidedly  favorable  prognosis. 

Treatment. — It  is  impossible  to  give  any  specific  rales  for 
treating  caries  and  necrosis  of  the  bony  parts  of  the  ear. 
Each  case  must  be  judged  by  itself,  under  the  general  rules 
of  treatment  that  have  been  given  as  appropriate  for  chronic 
suppuration  ;  the  chief  of  these  rules,  I  may  venture  to  repeat, 
are  a  thorough  removal  of  the  accumulating  pus  before  it  has 
time  to  produce  its  corroding  and  destructive  effects,  and 
careful  attention  to  the  general  health  and  habits  of  the  pa- 
tient. 

Gruber*  mentions  one  means  of  treating  caries  of  the  tem- 
poral bone,  in  which  I  have  no  experience,  but  of  which  he 
gives  a  favorable  report,  in  some  cases  where  the  severe  pain 
was  not  relieved  by  local  antiphlogistic  and  anodyne  treatment. 
This  is  the  actual  cautery.  The  iron  is  applied  at  several 
points  over  the  mastoid  process.  After  the  bony  slough  is 
removed,  an  irritating  salve  may  be  applied  to  continue  the 
counter  irritation.  Dr.  Post,  of  this  city,  also  speaks  well  of 
the  actual  cautery  as  a  less  painful  means  of  treating  mastoid 
periostitis  than  the  incision.  I  have  no  doubt,  judging  from 
a  recent  experience  in  a  case  of  Dr.  H.  G.  Newton's — which  I 
saw  in  consultation — where  Dr.  Newton  trephined  the  mas- 
toid process  for  continuous  and  severe  pain  referred  to  the 
middle  ear,  but  without  finding  dead  bone,  that  such  openings 
will  do  very  much  to  relieve  the  deep-seated  pain  of  caries 
that  is  referred  to  the  ear  and  the  brain. 

The  facilities  for  treating  chronic  suppuration,  since  we 
have  Politzer's  method  of  opening  the  Eustachian  tubes,  are 
much  greater  than  those  enjoyed  by  our  predecessors.  We 
may,  by  the  employment  of  this  method,  more  thoroughly 
cleanse  the  tympanic  cavity  from  pus  than  by  the  simple  use 
of  the  syringe.  In  the  chapter  on  chronic  suppuration,  a 
detailed  account  of  the  means  of  thoroughly  cleansing  the  ear 
has  already  been  given. 

*  Lehrbuck,  p.  552. 


444  CEREBBAL  ABSCESS. 

A  patient  with  caries  of  the  temporal  bone  should  be  made 
aware  of  the  gravity  of  his  condition,  so  that  he  and  his 
friends  may  be  on  the  lookout  for  serious  symptoms,  which 
may  be  promptly  treated,  and  that  they  may  not  fall  into  the 
error  of  supposing  that  no  harm  can  possibly  come  from  "  a 
simple  running  from  the  ear." 

If  polypi  or  granulations  have  occurred  in  connection  with 
caries  of  the  canal  or  tympanic  cavity,  they  should  be  removed 
with  care,  lest  severe  hemorrhage  occur,  or  other  harm  to  the 
parts.  The  galvano-cautery  has  proved  an  efficient  and  safe 
means  of  removing  such  granulations,*  and  of  causing  the 
bone  to  heal. 

Fatal  hemorrhage  has  occurred  from  caries  of  the  bony 
canal,  in  which  the  internal  carotid  passes  through  the  apes 
of  the  petrous  portion  of  the  temporal  bone,  as  well  as  from 
destruction  of  the  bony  wall  that  separates  the  mastoid  pro- 
cess from  the  lateral  sinus,  and  also  from  the  breaking  down 
of  the  thin  plate  of  bone  that  forms  the  floor  of  the  cavity  and 
separates  it  from  the  jugular  vein.  Fortunately  for  the  lives 
of  many  patients,  there  is  a  tendency  to  thickening,  or  hyper- 
plasia of  the  bony  walls  of  the  tympanum,  in  some  cases,  and 
thus  they  are  protected  from  the  corroding  effects  of  pus.f 

CEREBRAL   ABSCESS. 

The  proceedings  of  pathological  societies  and  surgical 
records  show,  that  abscess  of  the  cerebrum  more  frequently 
results  from  disease  of  the  middle  ear  than  from  any  other  sin- 
gle cause.  Of  seventy-sis  cases  of  cerebral  abscess  collected 
byDrs.  Gull  and  Sutton,^  twenty-five,  or  about  one-third,  were 

*  Archiv  fur  Ohrenheilkunde,  Bd.  VI.,  p.  116. 

f  Gruber,  Lehrbuch,  p.  543.  Gruber  states  tbat  Billroth  has  tied  the  com- 
mon carotid  artery  for  a  case  of  aural  bemorrbage,  which  occurred  not  from 
caries,  but  from  a  congenital  defect  in  tbe  bony  wall.  The  bemorrbage  ceased 
for  ten  days  after.  After  all  attempts  to  restrain  the  bemorrbage  were  fruit- 
less, Billroth  Hgated  tbe  left  carotid,  and  two  days  after  tbe  patient  died  from 
severe  hemorrhage  from  the  right  ear,  the  nose,  and  mouth.  A  child,  for 
whom  parents  would  not  allow  the  operation,  died  from  the  same  cause. 
Koeppe  reports  a  case  of  hemorrhage  from  the  lateral  sinus,  through  the  nose 
and  ear.     This  was  in  consequence  of  destruction  of  the  bone. 

%  Reynold's  System  of  Medicine,  vol.  ii.,  p.  544. 


CEREBRAL  ABSCESS.  445 

directly  traceable  to  chronic  suppurative  processes  in  the 
middle  ear.  Lebert,*  in  his  article  upon  this  subject,  con- 
siders that  aural  disease  is  the  cause  of  cerebral  abscess  in 
about  one-fourth  of  the  published  cases. 

There  is  usually  caries  in  connection  with  the  cerebral 
abscess,  but  cases  have  occurred  in  which,  although  the  dis- 
ease of  the  ear  extended  to  the  brain,  there  was  no  death  of 
bone.  The  anatomy  of  the  cavity  of  the  tympanum,  especially 
of  the  roof,  or  tegmen  tympani,  where  a  process  of  dura 
mater  actually  extends  into  the  tympanic  cavity,  and  where 
there  may  normally  be  a  gap  in  the  bone,  has  taught  us  how 
easily  this  may  occur.  The  cause  of  the  extension  of  a  sup- 
purative process  to  the  brain  is  undoubtedly  very  often  that 
which  Mr.  Toynbee  so  clearly  sets  forth  in  his  chapter  on  this 
subject — that  is,  the  non-escape  of  the  pus  externally  through 
the  membrana  tympani.  The  perforation  of  the  membrana 
tympani  in  acute  inflammation  usually  prevents  any  such  dis- 
aster as  the  passage  of  the  pus  to  the  brain  or  the  circulation. 

Rupture  of  the  membrana  tympani  is,  therefore,  a  con- 
servative process,  if  suppuration  has  once  been  established ; 
for  there  is  no  other  safe  way  of  escape  for  the  pus,  except 
through  the  Eustachian  tube — a  means  of  exit  which  is  one  of 
the  last  that  nature  chooses.  Abscess  of  the  brain  in  acute 
disease  was  only  once  observed  by  Mr.  Toynbee. 

A  direct  communication  usually  takes  place  between  the 
diseased  mastoid  or  petrous  portion  of  the  temporal  bone  with 
the  brain  substance  through  the  meninges,  but  the  dura  mater 
and  other  membranes  may  be  healthy,  and  even  a  portion  of 
healthy  brain  may  lie  between  the  diseased  bone  and  the  cere- 
bral abscess.  The  chronic  disease  of  the  ear  may  be  going  on 
very  well,  until  some  mechanical  injury — exposure  to  cold,  or 
the  like — sets  up  an  acute  process,  which  extends  to  the  brain 
through  the  delicate  bony  walls  of  the  tympanic  cavity,  or  the 
cancellous  structure  of  the  mastoid  bone. 

Patients  suffering  from  chronic  suppuration  of  the  middle 
ear  cannot  be  too  much  guarded  against  blows  or  falls  upon 
the  ear,  or  against  exposures  to  sudden  changes  of  temperature, 

*  Virchow's  Arcliiv,  Bd.  X.,  p.  391. 


446  CEKEBEAL  ABSCESS. 

drafts  of  air,  or  the  like ;  for  the  table  of  cases  appended  to  this 
chapter,  shows  that  meningitis,  cerebral  abscess,  and  pyaemia 
may,-  from  such  exciting  causes,  be  the  termination  of  a  puru- 
lent discharge  from  the  ear. 

The  symptoms  of  brain  disease  are  sometimes  very  insi- 
dious. At  times  there  is  a  chill  or  a  convulsion,  or  nausea 
and  vomiting  ;  at  others,  only  increased  pain  in  the  ear,  fol- 
lowed in  rapid  order  by  paralysis,  coma,  and  death.  In  very 
rare  cases  there  are  absolutely  no  symptoms,  except  those 
of  a  chronic  suppurative  process  in  the  ear,  until  death 
occurs. 

The  table  of  fatal  cases  of  aural  disease  resulting  from 
chronic  suppurative  processes,  that  has  just  been  alluded  to, 
was  compiled  from  various  sources,  in  order  to  show  the 
variable  character  of  brain  symptoms  supervening  on  otitis 
media  purulenta,  and  the  anxiety  with  which  such  a  case, 
especially  if  united  with  caries  or  necrosis  of  bone,  should  be 
regarded. 

It  is  interesting  to  note  how  slowly  the  profession  came  to 
recognize  the  fact  that  when  pus  was  found  in  the  brain  com- 
municating with  the  ear,  that  it  was  on  its  way  inwards,  and 
not  making  an  external  opening.  It  seems  to  have  been  hard 
for  the  medical  men  of  a  few  generations  back,  to  believe  that 
aural  disease  could  cause  any  serious  affection,  or  that  it  was 
a  matter  of  much  account,  although  people  were  dying  all 
about  them  from  the  results  of  aural  disease  alone.  Lebert* 
says  that  Morgagni,  "  with  his  good  tact  and  close  observa- 
tion of  Nature,"  discovered  that  the  ear  was  often  the  cause 
of  purulent  affections  of  the  circulation  and  brain  substance ; 
but  Itard  took  a  step  backward,  and  discovered  a  kind  of 
cerebral  abscess  which  broke  out  through  the  ear.  Lalle- 
mand  again  placed  the  subject  in  its  right  light,  and  showed, 
what  we  now  clearly  see,  that  in  cases  of  cerebral  abscesses 
occurring  in  connection  with  suppuration  of  the  ear,  that  the 
organ  of  hearing  was  the  part  first  affected. 

It  is  generally  believed  that  a  suppurative  process  in  the 
ear  is  necessary  for  the  production  of  an  abscess  of  the  brain, 

*  Virchow's  Archiv,  Bd.  IX.,  p.  382. 


PY2EMIA.  447 

and  this  is  probably  the  fact ;  but  one  case  that  I  observed, 
leads  me  to  suspect  that  there  may  be  such  a  thing  as  a 
chronic  cerebral  abscess  leading  to  disturbing  aural  symp- 
toms, such  as  tinnitus  aurium  and  pain  in  one  side  of  the  head, 
without  any  primary  aural  affection.  I  treated  a  gentleman 
of  about  twenty-nine  years  of  age,  for  some  months,  for  such 
symptoms  as  have  been  indicated,  and  when  he  died  a  cere- 
bral abscess  was  found.  He  could  hear  the  watch  for  but  three 
inches  from  the  left  ear,  which  was  the  affected  one,  and  the 
drum  membrane  was  sunken.  I  supposed  the  case  to  be  one 
of  chronic  proliferous  inflammation  of  the  middle  ear.  The 
patient  got  no  relief  ;  he  became  very  despondent  on  account 
of  his  tinnitus  aurium  and  pain,  gave  up  his  business,  and  died 
at  Sag  Harbor,  L.  I.,  of  malignant  pustule,  about  two  years 
and  a  half  after  I  first  saw  him,  and  three  years  and  a  half 
after  his  first  aural  symptoms.  Dr.  Gso.  A.  Sterling,  of  that 
place,  made  a  post-mortem  examination.  He  found  "  great 
injection  of  the  pia  mater  over  petrous  portion  of  temporal 
bone,  and  an  abscess  about  the  size  of  a  ten  cent  piece  in  the 
brain  substance.  It  was  bounded  by  inflammatory  adhesions, 
and  contained  about  ten  drops  of  pus.  The  abscess  was  situ- 
ated on  the  left  side,  in  the  superior  lobe,  one  inch  from  the 
median  line  and  two  inches  from  the  coronal  suture."  This 
patient  never  had  a  suppurative  inflammation  in  the  ear,  and 
it  is  possible  that  the  cerebral  abscess  was  the  cause  of  his 
very  distressing  symptoms,  although  the  data  are  not  full 
enough  to  allow  us  to  give  a  positive  opinion.  There  is  no 
account  of  an  examination  of  the  temporal  bone. 

The  text-books  on  pathology  give  very  full  accounts  of 
cerebral  abscess.  The  author  has  had  but  the  space  to 
plainly  mark  them  out  as  one  of  the  consequences  of  chronic 
suppuration  of  the  middle  ear. 

PYEMIA. 

The  author  has  already  (on  page  292)  related  a  case 
which  shows  that  pyaemia,  or  metastatic  abscesses,  from  the 
entrance  of  pus  into  the  circulation  through  the  mastoid 
veins  or  the  lateral   sinus,  may  result  from   aural  disease. 


448  PY2EMIA  AND  PAKALYSIS. 

Mr.  Prescott  Hewitt,"  in  1881,  related  a  similar  case,  and  with 
the  like  happy  result  of  recovery.  Mr.  Hewitt's  case  was  in 
substance  as  follows :  A  young  lady,  eighteen  years  of  age, 
had  a  discharge  from  the  ear,  as  a  consequence  of  measles. 
About  four  weeks  after  the  occurrence  of  the  discharge,  she 
was  seized  with  severe  chills,  which  were  followed  by  much 
fever,  a  furred  tongue,  and  typhoid  symptoms,  with  suppres- 
sion of  the  discharge.  When  Mr.  Hewitt  saw  the  patient  the 
chills  continued,  the  skin  had  assumed  an  earthen  hue,  and 
the  fever  was  intense.  The  intellect  was  clear,  but  there  was 
pain  extending  down  the  side  of  the  neck,  along  the  course  of 
the  jugular  vein,  and  the  head  was  inclined  to  that  side. 
There  was  swelling  at  the  base  of  the  neck.  In  eight  days 
pus  appeared  in  one  of  the  sterno-clavicular  articulations.  In 
a  few  days  one  knee  became  involved,  and  symptoms  of  pneu- 
monia appeared,  which  soon  subsided.  In  about  seventeen 
days  from  the  beginning  of  the  phlebitis,  swelling  and  pain 
occurred  over  one  of  the  hip-joints,  a  deep  abscess  formed, 
but  it  was  opened  early,  and  the  joint  did  not  become  involved. 
The  patient  ultimately  recovered  under  treatment  by  wine  and 
morphia. 

This  case  and  the  one  already  referred  to,  give  the  clin- 
ical features  of  purulent  infection  from  suppuration  in  the 
ear.  The  pathological  characteristics  of  the  disease  are  seen 
in  the  table  of  fatal  cases  appended  to  this  chapter.  Professor 
Lebertt  has  given  us  the  fullest  account  of  the  inflammations 
of  the  sinuses  that  may  lead  to  purulent  infection ;  but  the 
proper  limits  of  this  volume  do  not  allow  of  a  fuller  discussion 
of  this  dangerous,  but  by  no  means  hopeless  disease.     * 

PAEALYSIS. 

Paralysis  of  the  seventh  nerve,  as  it  passes  through  the 
tympanic  cavity,  in  the  Fallopian  canal,  must  of  necessity  be 
a  consequence  of  many  suppurative  and  carious  affections  of 
this  part,  and  yet  it  cannoi  be  said  to  be  a  frequent  affection 
in  the  course  of  chronic  suppuration  of  the  middle  ear.     In 

*  London  Lancet,  Feb.  2,  1861. 

f  Virchow's  Archiv,  Bd.  IX.,  p.  381. 


PAEALYSIS.  449 

the  greater  number  of  the  cases  in  which  it  occurs,  it  is  perma- 
nent, from  the  fact  that  the  nerve  tissue  is  destroyed  by  the 
ulcerative  process  ;  but  I  have  seen  cases  of  temporal  paraly- 
sis of  the  seventh,  which  were  probably  due  to  pressure  upon 
the  nerve  trunk  ;  for,  when  the  suppuration  of  the  ear  was 
checked,  the  functions  of  the  nerve  were  restored,  and  the  face 
resumed  its  normal  appearance. 

Paralysis  of  other  parts  of  the  body,  and  complete  hemi- 
plegia, may  occur  in  the  course  of  meningitis  and  cerebral 
abscess ;  but  these  necessary  consequences  of  the  destruction 
of  brain  substance  hardly  require  a  separate  notice. 

It  is  possible  that  a  blood  clot  might  form  between  the 
dura  mater  and  the  bone,  from  rupture  of  a  branch  of  the 
middle  meningeal,  from  caries  of  the  temporal  bone,  and  hemi- 
plegia be  induced  by  pressure  communicated  to  the  motor  tract, 
or  as  Mr.  Hutchinson  says,  as  quoted  by  Dr.  Hughlings  Jack- 
son,* by  squeezing  the  blood  from  the  corpus  striatum,  or  tha- 
lamus opticus.  The  author  has  published  two  cases  of  hemi- 
plegia, occurring  in  coincidence  with  chronic  suppuration  of 
the  middle  ear,t  which  are  here  reproduced  as  good  illustra- 
tions of  the  subject,  although  it  is  not  claimed  that  they  should 
be  regarded  as  positively  consequences  of  chronic  suppuration. 
A  boy  ten  years  of  age  was  brought  to  me  for  advice  on  May  10, 
1869.  He  had  had  a  discharge  from  the  left  ear  since  he  was 
an  infant,  and  about  four  weeks  ago  he  was  affected  with  a  num- 
ber of  paralytic  symptoms  that  came  on  gradually.  He  be- 
came unable  to  speak  distinctly,  or  to  swallow  his  food  properly, 
and  finally  he  could  not  walk,  steadily.  There  was  paralysis  of 
the  seventh  pair  on  the  left  side,  and  of  the  left  arm  and  leg,  so 
that  he  could  not  grasp  well,  and  he  dragged  his  foot  in  walking. 
These  symptoms  came  on  gradually,  in  the  course  of  some 
hours,  a  fact  which  indicated  hemorrhage  between  the  dura 
mater  and  the  bone.  The  right  membrana  tympani  was  intact, 
but  thickened,  and  it  had  no  light  spot.  The  left  was  ulcerated 
and  perforated.  Its  remains  were  very  vascular.  His  hearing 
distance  was  ^"  from  the  right  ear,  and  -fa"  from  the  left. 
Under  the  usual  treatment  the  membrana  tympani  healed,  and 

*  Reynold's  System  of  Medicine,  vol.  ii.,  p.  505. 

f  Transactions  of  the  American  Otological  Society,  1870. 

29 


450  PAEALYSIS. 

the  hearing  power  became  normal.  The  paralysis  was  nearly 
gone  when  he  disappeared  from  observation. 

June  8,  1870. — The  patient  was  again  brought  to  me,  and 
his  mother  stated  that  he  was  seized  with  dizziness  and  loss  of 
sight  while  at  school.  He  became  so  affected  that  he  was  fif- 
teen minutes  going  two  or  three  blocks,  and  he  was  stupid 
when  he  reached  home,  although  he  had  complete  control  of 
all  his  limbs.  He  had  sight  enough  to  go  about,  but  not  to 
read.  Two  months  after  this  attack,  his  vision  was  \  in  the 
right  eye,  and  \  on  the  left.  The  field  of  vision  was  greatly 
limited  on  the  periphery.  The  ophthalmoscope  did  not  detect 
any  lesion  in  the  fundus  oculi.  Under  expectant  treatment 
the  boy  slowly  recovered  his  vision. 

The  second  case  was  that  of  a  farmer,  aged  62,  whom  I 
saw  in  October,  1869,  in  consultation  with  Dr.  Losee,  of  Red 
Hook,  N.  Y.  The  patient  had  suffered  from  chronic  suppura- 
tion of  the  right  ear,  since  he  was  a  child.  Occasionally  acute 
attacks  would  occur,  culminating  in  abscesses  of  the  mastoid. 
For  six  years  past,  the  ear  had  been  very  quiet.  About  six 
weeks  before  I  saw  the  patient,  he  was  seized  with  hemiplegia 
of  the  left  half  of  the  body,  coming  on  in  the  course  of  a  few 
hours.  When  I  saw  him  he  was  slowly  recovering  from  the 
paralysis.  The  hearing  power  on  the  right  side  was  com- 
pletely destroyed.  The  cavity  of  the  tympani  was  exposed 
and  empty.  There  was  a  cartilaginous  band  extending  across 
the  canal,  which  I  divided,  and  found  that  it  contained  small 
bits  of  dead  bone,  which  seemed  to  come  from  the  posterior 
wall  of  the  canal.  The  patient  fully  recovered  from  the  para- 
lysis, and  is  still  living. 

Dr.  Hughlings  Jackson,*  in  lecturing  upon  epileptic,  or  epi- 
leptiform convulsions  occurring  in  connection  with  discharges 
from  the  ear,  says,  that  arguing  from  the  fact  that  cerebral  or 
cerebellar  abscess  may  follow  disease  of  the  ear,  "it  becomes 
legitimate  to  inquire  if  minute  changes  in  tracts  of  the  brain 
may  not  occasionally  follow  a  disease  of  this  apparatus,  which 
changes  may  allow  occasional  discharge  of  nerve  force."  He 
is  anxious  to  learn  if  epileptiform  seizures  occurring  in  cases 

*  British  Medical  Journal,  June  26,  1869. 


PAEALYSIS.  451 

of  discharge  of  pus  from  the  ear,  may  not  result  from  minute 
changes  in  venous  tracts.  There  are  still  great  gaps  in  our 
knowledge  of  epilepsy  and  paralysis  dependent  upon  aural 
disease.  Dr  Jackson*  urges  that  in  all  cases  of  hemiplegia  in. 
children  the  ear  should  be  examined,  and  that  in  such  autop- 
sies the  possibility  of  venous  thrombosis  from  aural  disease 
should  be  borne  in  mind. 

The  table  on  the  next  page,  which  I  have  compiled  from 
various  sources,  illustrates  in  a  striking  manner  the  fatal  con- 
sequences of  some  cases  of  aural  disease.  Taken  in  connec- 
tion with  the  fact  already  stated,  that  suppuration  of  the  ear 
is  more  frequently  the  cause  of  cerebral  abscess  than  any 
other  one  disease,  these  cases  form  a  complete  justification,  if 
one  were  needed,  for  the  giving  up  so  much  space  to  the  con- 
sequences of  chronic  suppuration  of  the  middle  ear.  If  the 
table  shall  startle  some  mind  hitherto  inattentive  to  this  sub- 
ject, into  a  realization  of  its  grave  importance,  and  lead  to  a 
more  careful  consideration  of  an  ulcerated  middle  ear,  it  will 
have  accomplished  its  object. 

*  London  Medical  Times  and  Gazette,  July  13, 1873. 


452 


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PART  III. 


THE    INTERNAL    EAR. 


CHAPTER    XVIII. 

ANATOMY  OF  THE  INTERNAL  EAR. 

Galen  named  the  internal  ear  the  labyrinth,  although  he 
did  not  attempt  to  describe  its  various  parts.  This  name 
it  continues  to  bear,  although  so  much  labor  has  been  given 
to  its  exploration,  that  we  now  have  the  thread  to  guide  us 
through  its  devious  passages.  Yet  in  our  own  time,  a  part 
of  this  internal  ear — the  cochlea — is  still  the  subject  of  vig- 
orous research  and  heated  discussion,  and  different  views 
are  yet  entertained  by  competent  authorities  as  to  the  true 
description  of  its  component  parts.  I  shall  attempt  to  give 
the  student  such  an  account  of  its  anatomy  as  shall  serve  as  a 
basis  for  the  study  of  its  physiology  and  diseases,  without 
entering  into  the  discussion  of  the  points  still  unsettled.* 

The  internal  ear  may  be  conveniently  studied  by  dividing 
it  into  the  following  parts  : 

1.  The  vestibule. 

2.  The  semicircular  canals. 

3.  The  cochlea. 

4.  The  auditory  nerve. 

We  shall  first  study  the  osseous  envelope  of  these  parts, 
and  then  consider  their  contents  ;  the  latter  being,  of  course, 
far  more  important. 

THE  VESTIBULE. 

The  vestibule  is  considered  the  essential  part  of  the  inter- 
nal ear  by  all  authorities.     A  part  answering  to  the  vestibule 

*  In  compiling  this  anatomical  sketch,  the  author  has  been  at  times  com- 
pelled, in  order  to  avoid  inaccuracy  of  statement,  to  use  the  exact  words  of  the 
■writer  whose  work  he  has  used.  He  has  not  inserted  the  quotation  marks, 
but  the  authorities  he  has  consulted  will  be  found  at  the  end  of  the  chapter. 
The  text-book  of  Henle  has  formed  the  basis  of  the  description  of  the  micro- 
scopic anatomy  of  the  labyrinth. 


462 


VESTIBULE. 


is  to  be  found  in  all  animals  in  whom  an  auditory  apparatus 
can  be  detected.  It  is  the  seat  of  the  principal  expansion  of  the 
auditory  nerve  upon  the  saccule,  soon  to  be  described.  This 
saccule  floats  in  the  perilymph  and  communicates  through 
that  fluid  with  the  membrane  of  the  fenestra  ovalis,  and  con- 
sequently with  the  air  in  the  tympanic  cavity. 


PVi.  SO. 


Horizontal  Section  through  the  Lower  Half  of  the  Left  Ear.    After  a  Photograph— ffildinger. 
Made  from  a  preparation  softened  by  hydrochloric  acid  and  then  hardened  in  alcohol. 

1.  Cartilaginous  portion  of  the  auditory  canal,  having  a  great  anterior  convexity.  At  figure  1 
the  posterior  wall  presses  well  into  the  canal,  so  that  it  is  the  narrowest  at  this  point.  2. 
Cartilages  of  the  anterior  wall  of  the  canal.  3.  The  osseous  part  of  the  canal.  4.  3fem~ 
brana  tympani.  5.  Cavity  of  the  tympanum.  6.  Stapes  bone.  7.  Stapedius  muscle.  8. 
Section  of  facial  nerve.  9.  Tensor  tympani  muscle.  10.  Auditory  nerve.  11.  Nerve  of 
the  cochlea.  12.  Section  of  the  cochlea.  13.  Inferior  nerve  of  the  amputtm.  14.  Section 
of  the  sacculus  hemillipticus.  15.  Sacculus  hemisphcericus.  16.  Section  of  membranous 
semicircular  canal. 


The  vestibule  is  an  irregularly-shaped  osseous  cavity,  the 
diameter  of  which  from  above  downwards,  as  also  from  behind 
forwards,  is  about  one-fifth  of  an  inch.  It  is  about  one-tenth 
of  an  inch  between  its  inner  and  outer  wall.  The  semicircular 
canals  open  into  it  by  five  orifices  behind  the  cochlea,  by  a 
single  one  in  front.  The  fenestra  ovalis  is  on  its  outer  wall ; 
on  its  inner  are  several  minute  holes,  making  up  the  maculae 
cribrosae  for  the  entrance  of  a  portion  of  the  auditory  nerve 
from  the  internal  auditory  canal.     At  the  posterior  part  of  the 


VESTIBULE. 


463 


inner  wall  is  the  orifice  of  the  aqueductus  vestibuli,  a  fine 
canal  penetrating  the  vestibule  from  the  posterior  surface  of 
the  petrous  bone,  and  contains  a  tubular  prolongation  of  the 
lining  membrane  of  the  vestibule,  ending  in  the  cranial  cavitv. 
between  the  layers  of  the  dura  mater. 


Fig.  90. 


The  Left  Vestibule,  with  the  Semicircular 

Canals,  from  an  Adult,  seen  from 

within  .—Budinger. 

1.  Tlie  horizontal  semicircular  canal.  2.  The 
upper  semicircular  canal.  3.  The  poste- 
rior semicircular  canal.  4.  A  brist  e  is 
passed  through  the  aqueductus  vestibuli, 
and  passes  into  the  openin  g  of  two  canals, 
and  appears  on  the  upper  wall  of  the  ves- 
tibule. 5.  The  mouths  of  the  osseous  am- 
pulla of  upper  and  horizontal  semicircu- 
lar canals.  6.  The  opening  of  the  lower 
ampulla  of  the  posterior  semicircular 
canal,  beloio  the  numbers  6  and  7.  7. 
The  lower  opening,  in  which  the  bristle  is 
seen,  represents  the  opening  Of  the  com- 
monpassage  for  two  semicircular  canals. 


The  Vestibule.— After  Budinger. 

1.  The  osseous  lamina  spiralis  of  the  cochlea, 
beginning  below  and  posteriorly  on  the 
wall  of  the  vestibule.  2.  The  scala  tym- 
pani  and  the  fenestra  rotunda.  3.  The 
scala  vestibuli.  4.  Fenestra  ovalis.  5. 
The  posterior  inferior  wall  of  the  lower 
ampulla,  with  the  inferior  macula  cri- 
brosa,  ivhich  serves  as  a  passage  for  the 
fibres  of  the  vestibular  nerve  to  the  lower 
ampulla.  6.  Fovea  rotunda,  or  recessus 
hemisphoiricus.  In  its  centre  are  a  num- 
ber of  fine  openings,  the  macula  cribrosa 
media,  through  these  the  fibres  of  the 
middle  branches  of  the  vestibular  nerve 
pass  to  the  round  saccule,  which  is  the 
blind  vestibular  end  of  the  scala  vesti- 
buli. 7.  The  upper  portion  of  the  recessus 
hemillipticus  in  which  is  the  upper  ma- 
cula cribrosa.  8.  The  lower  portion  of 
the  recessus  hemillipticus,  which  passes 
without  any  distinct  dividing  line  into 
the  semicircular  canals. 


The  maculae  cribrosse  on  the  inner  wall  of  the  vestibule  are 
to  be  seen  with  the  naked  eye  on  the  newly  born,  but  in  the 
adult  they  are  only  to  be  seen  by  means  of  the  microscope. 
Henle  describes  four  little  groups,  each  having  five  openings, 
and  each  series  of  foramina  make  up  what  is  known  as  a  ma- 
cula cribrosa.  Through  the  macula  cribrosa  superior,  the 
nerves  pass  to  the  utricle  and  to  the  ampullae  or  flask-shaped 
openings  of  the  anterior  vertical  and  the  horizontal  semicircu- 
lar canals.     The  nerve  fibres  to  the  posterior  semicircular 


464  VESTIBULE. 

canals  pass  through  the  inferior  macula  cribrosa,  and  those  to 
the  saccule  through  the  macula  cribrosa  media.  Finally, 
through  the  fourth  macula  cribrosa  passes  the  twig  of  the 
small  branch  of  the  cochlear  nerve.  The  scala  vestibuli  of  the 
cochlea  begins  on  the  anterior  apex  of  the  vestibule. 

The  lateral  wall  of  the  vestibule  is  interrupted  by  the 
fenestra  ovalis,  but  it  is  so  completely  and  smoothly  closed  by 
the  base  of  the  stapes  bone,  that  the  inner  surface  of  this  wall 
of  the  vestibule  appears  even.  On  the  medial  wall  are  two 
depressions,  called  respectively  the  recessus  sphsericus  and  the 
recessus  ellipticus.  A  minute  elevation  between  them  is  called 
the  crista  vestibuli.  Just  above  the  recessus  ellipticus  opens 
the  ampulla  or  flask-like  orifice  of  the  anterior  vertical  semi- 
circular canal.  The  two  vertical  canals  open  in  the  angle  of 
the  posterior  and  medial  wall.  On  the  same  line,  but  a  little 
higher  in  the  middle  of  the  posterior  wall,  is  the  posterior 
opening  of  the  horizontal  semicircular  canal.  The  lower 
opening  of  the  posterior  vertical  canal  is  in  the  angle  formed 
by  the  posterior,  lower,  and  medial  wall  of  the  vestibule.  The 
anterior  ampulla  of  the  horizontal  canal  lies  on  the  lateral 
wall  between  the  fenestra  ovalis  and  the  ampulla  of  the  ante- 
rior vertical  semicircular  canal. 

THE  SEMICIRCULAR  CANALS. 

The  semicircular  canals  are  half-elliptical  or  C-shaped 
canals  which  proceed  from  the  vestibule  and  return  to  it  again. 
They  are  three  in  number.  The  horizontal  lies  with  its  convex- 
ity directed  laterally.  The  other  two  are  vertical  in  position, 
forming  a  right-angle  with  each  other.  The  two  openings  of 
the  posterior  vertical  semicircular  canals  are  near  each  other 
and  at  about  the  same  height.  The  openings  of  the  posterior 
vertical  canals  are  above  each  other.  The  horizontal  canal 
is  surrounded,  as  it  were,  by  the  two  vertical  ones. 

There  are  considerable  variations  in  different  individuals, 
according  to  Henle,  in  the  length  and  curvature  of  the  semi- 
circular canals,  yet  the  general  shape  of  these  parts  remains 
the  same. 

The  length  of  the  anterior  vertical  canal,  measured  on  the 


SEMICIRCULAR  CANALS. 


465 


convex  border,  with  the  ampulla  and  the  common  eras,  is  about 
20  millimetres  ;  that  of  the  posterior  is  22mm.,  of  the  horizon- 


Fig.  92. 


Flo.  93. 


Osseous  CocMea  and  Semicircular  Canals, 
with  Stapes  Bone.  Left  Ear  of  Adult. 
—After  Biidinger. 


Bight  Osseous  Vestibule,  Semicircular  Ca- 
nals, Cochlea,  and  Ossicula  Auditus  of 
Newly-born. — After  Biidinger. 


tal  5mm.  The  part  common  (canalis  communis)  to  the  two 
vertical  canals  is  from  2  to  3  millimetres  in  length.  The 
diameter  in  a  grown  man  varies  from  1.3  to  1.7  millimetres. 
Wharton  Jones  makes  their  caliber  about  one-twentieth  of  an 
inch  in  a  direction  from  the  concavity  to  the  convexity  of  their 
curve. 

Fig.  94. 


The  Bight  Osseous  Labyrinth  of  a  newly-born  Subject  opened  on  its  Posterior  Surface.— 

After  Biidinger. 

.  Cochlear  fenestra.  2.  The  osseous  spiral.  3.  The  osseous  spiral  canal  of  the  cochlea— canalis 
spiralis  cochleae— divided  by  the  spiral  into  two  parts,  scala;,  or  stairways,  the  loioer  the 
scala  tympani,  the  upper  the  scala  vestibuli.  4.  The  basis  of  the  internal  auditory  canal, 
with  the  entrance  to  the  Fallopian  canal  and  the  macula,  cribrosce.  The  latter  receive  the 
fibres  of  the  auditory  nerve,  and  the  vessels  entering  with  it  into  the  labyrinth.  5.  The 
osseous  vestibule,  opened  on  its  posterior  wall.  6.  The  posterior  semicircular  canal.  7. 
The  upper  semicircular  canal.    9.  Horizontal  semicircular  canal. 


Since  the  semicircular  canals  all  open  at  both  ends  into 
the  vestibule,  there  would  be  six  orifices  were  not  one  of  the 
orifices  common  to   two  of  the  canals.     There  are,  conse- 
quently, five.    These  openings  are  called  ampullae  (flasks)  from 
30 


466  SEMICIKCULAK  CANALS. 

their  shape,  and  are  more  than  twice  the  diameter  of  the 
tubes.  The  inner  extremity  of  the  superior  vertical  canal 
has  a  common  opening  into  the  vestibule  with  the  posterior 
vertical. 

According  to  Henle,*  in  the  later  years  of  life  the  semi- 
circular canals  increase  in  length ;  the  horizontal  canal  in- 
creases the  most,  and  the  anterior  vertical  the  least.  The 
canals  also  increase  very  slightly  in  width  ;  about  0.7mm. 
according  to  Hyrtl. 

The  functions  of  the  semicircular  canals,  according  to  the 
experiments  of  Flourenst  and  Goltz,|  are  to  preserve  the  equi- 
librium of  the  head,  and  consequently  of  the  body.  Goltz 
believes  that  the  semicircular  canals  are  not,  so  to  speak, 
essential  to  the  function  of  hearing. 

THE  COCHLEA. 

This  part  of  the  internal  ear  is  so  named  from  its  resem- 
blance to  a  common  snail ;  a  resemblance  which  is  very 
marked.     It  is  one  of  the  most  remarkable  instances  iu  the 


Section  through  the  Apex  of  the  Eight  Osseous  Cochlea,  parallel  with  the  base. 
a.  Lower  surf 'ace  of  the  section,    b.  Upper  surf  ace  of  the  section,    c,  *.  Canal  of  facial  neroe. 

whole  body  of  the  compact  packing  of  very  important  parts. 
Wharton  Jones  §  remarks  of  its  function,  that  the  presence  of 
a  cochlea  is  evidence  of  a  very  advanced  condition  of  the  organ 

*  Lehrbuch,  p.  762. 

t  Von  Troltsch,  second  American  edition,  p.  505. 

%  Knapp,  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1.     Brun- 
ner,  ibid.,  1.  c. 

§  Cyclopedia  of  Anatomy  and  Physiology,  p.  569. 


COCHLEA. 


467 


of  hearing  ;  "beyond  this  we  can  arrive  at  no  definite  conclu- 
sion in  the  present  state  of  our  knowledge."  Recent  investiga- 
tions, however,  render  it  safe  to  say  that  one  of  the  functions 
of  the  cochlea  is  to  discriminate  between  tones.  The  fibres 
of  Corti  connected  to  the  cells  that  are  to  be  described,  being 
the  keys  of  an  instrument  of  more  than  a  thousand  strings. 


Fig.  96. 


Section  of  the  Temporal  Bone,  vertical  to  its  Long  Axis— Posterior  Surf  ace  of  the  Section. 

—After  Benle. 
m.  Meatus  auditorius  internus.    c,  t,  t.  Canal  of  the  tensor  tympani  muscle,    s.  m.  Canalis 

spiralis  modioli. 

The  osseous  cochlea  lies  in  front  of  the  vestibule,  and  be- 
hind the  carotid  canal,  and  forms  the  promontory  by  pressing 
out,  as  it  were,  the  bone  towards  the  tympanic  cavity.  Inwards 
it  strikes  upon  the  blind  end  of  the  internal  auditory  canal. 
The  cochlea  is  aptly  compared  to  a  tube  tapering  towards  one 
extremity  where  it  ends  in  a  cul-de-sac,  and  which  is  coiled  like 
the  shell  of  a  snail  round  an  axis  or  central  pillar.  Then  we 
must  suppose  this  tube  divided  into  passages  by  a  thin  parti- 
tion running  throughout  its  length,  and  spirally  around  its  axis. 

The  tube  of  which  the  cochlea  is  formed — the  canalis 
spiralis  cochleae,  is  about  an  inch  and  a  half  long,  about  one- 
tenth  of  an  inch  in  diameter  at  its  commencement,  and  about 


468 


COCHLEA. 


one-twentieth  at  its  termination.  It  makes  two  turns  and  a 
half  turn,  in  a  direction  from  below  upwards,  from  left  to  right 
in  the  right  ear,  and  from  right  to  left  in  the  left  ear.  The 
apex  of  the  coil  is  directed  forwards  and  outwards.  The  base 
of  the  spiral  tube  runs  into  the  vestibule.  The  cul-de-sac  at 
the  apex  forms  a  kind  of  vaulted  roof  called  the  cupola. 


Osseous  Cochlea  {Bight)  of  the  Newly-born,  opened  from  the  Outer  Surface.— After  Henle. 

e,  v.  Scala  vestibuli.  b,  t.  Scala  tympani.  1,  6.  Lamina  spiralis,  c,  s.  Crista  semilunaris. 
a,  c.  Inner  opening/  of  the  aqueductus  cochlea,,  c,  m.  Canalis  centralis,  s,  m.  Canalis 
spiralis  modioli. 

The  first  turn  of  the  cochlea  has  a  circular  sweep  of  a 
quarter  of  an  inch,  and  is  wider  than  the  rest.  It  is  separated 
from  the  second  turn  by  a  soft  bony  substance,  which  extends 
a  little  way  between  the  second  and  third.  The  axis  is  com- 
posed of  the  internal  walls  of  the  tube  of  the  cochlea  and  the 
central  space  circumscribed  by  their  turns,  in  which  space  are 
the  filaments  of  the  cochlear  nerve  running  in  small  bony 
canals.  The  axis  is  about  one-seventh  of  an  inch  in  thickness 
at  the  first  turn,  but  it  becomes  thinner  from  the  second  turn, 
on  to  its  termination.  The  axis  terminates  within  the  last  half 
coil  or  cupola,  in  a  delicate  bony  lamella,  which  resembles  the 
half  of  a  funnel,  divided  longitudinally,  and  called  the  infundibu- 
lum  (funnel).  Wharton  Jones  compares  the  appearance  of  the 
axis  of  the  cochlea  after  the  outer  walls  have  been  removed, 


COCHLEA. 


469 


to   the   ordinary   pictorial  representations   of   the  tower  of 
Babel. 

The  cavity  of  the  cochlea  is  divided  into  two  parts  or  pas- 
sages, called  scalce,  by  a  thin  osseous  and  membranous  spiral 
lamina,  lamina  spiralis  ossea.  The  lower  one  communicates 
with  the  cavity  of  the  tympanum  through  the  fenestra  rotunda, 
the  upper  with  the  recessus  hemisphgericus  (see  Fig.  94,  of  the 
vestibule).  The  former  space  is  therefore  called  the  scala  tym- 
pani, the  latter,  scala  vestibuli.  In  the  scala  tympani,  exactly 
behind  the  membrana  tympani  secondaria,  which  closes  the 


Bight  Osseous  Cochlea,  opened  anteriorly. 

1.  s.  Lamina  spiralis,    h.  Hamulus,    f.  c.  Fenestra  cochleae,    t.  Section  of  the 
middle  wall  of  the  coch'ea.    ft.  Its  upper  extremity,    m.  d.  Modiolus. 


fenestra  rotunda,  is  an  opening  called  the  entrance  of  the 
aqueduct  to  the  cochlea.  The  two  scalse  communicate  at  the 
apex  of  the  cochlea  by  a  common  opening  called  the  helico- 
trema(a  twisted  foramen).  This  communication  exists  in  con- 
sequence of  the  want  of  a  lamina  spiralis  in  the  last  half  coil 
of  the  canal. 

Two  very  small  canals  called  aqueducts  open  by  one  ex- 
tremity into  the  labyrinth,  and  by  the  other  on  the  surface  of 
the  petrous  portion  of  the  temporal  bone.     One  opens  into 


470  COCHLEA. 

the  vestibule,  and  has  already  been  alluded  to,  and  is  called 
the  aqueductus  vestibuli ;  the  other  enters  into  the  tympanic 
scala  of  the  cochlea,  and  is  called  the  aqueductus  cochleae. 
The  length  of  the  aqueduct  of  the  vestibule  is  about  one-third 
of  an  inch  ;  that  of  the  aqueduct  of  the  cochlea  is  about  one- 
quarter  of  an  inch.  The  aqueduct  of  the  vestibule  begins  by 
a  groove  immediately  below  and  in  front  of  the  opening  com- 
mon to  the  two  vertical  semicircular  canals.  From  this  the  aque- 
duct turns  itself  around  the  inner  wall  of  the  common  canal, 
and  runs  downwards  and  backwards.  It  gradually  widens 
and  opens  under  a  thin  osseous  projection,  seen  a  little  be- 
hind the  middle  of  the  posterior  and  inner  surface  of  the  pe- 
trous bone,  just  above  the  jugular  fossa.  From  the  fossa  there 
is  a  narrow  groove  running  to  the  opening  of  the  aqueduct. 

Fig.  99. 


Apex  of  the  Left  Osseous  Cochlea  opened  to  show  the  End  of  the  Lamina  Spiralis.    After 

Henle. 

The  aqueduct  of  the  cochlea  begins  by  a  very  small  open- 
ing in  the  lower  wall  of  the  scala  tympani,  immediately  above 
the  fenestra  rotunda.  It  passes  downwards,  inwards,  and 
forwards  in  the  inner  wall  of  the  jugular  fossa,  and  opens  at 
the  bottom  of  a  triangular  depression,  situated  towards  the 
middle  of  the  edge  which  limits  the  inner  and  inferior  surfaces 
of  the  petrous  bone,  and  below  the  internal  auditory  canal. 

THE  MEMBRANOUS  LABYRINTH. 

Tlie  Auditory  Nerve  {Nervus  acusticus).  —  The  auditory 
nerve,  or  portio  mollis  (soft  part  of  the  7th  nerve),  is  the 


COCHLEA.  471 

nerve  of  the  sense  of  hearing,  and  is  distributed  exclusively 
to  the  internal  ear.  The  auditory  nerve  arises  from  numer- 
ous white  lines,  or  striae  (linse  transversa),  which  come  from 
the  posterior  median  fissure  in  the  anterior  wall,  or  floor 
of  the  fourth  ventricle.  It  is  also  connected  with  the  gray 
matter  of  the  medulla.  The  roots  of  the  nerve  are  con- 
nected, on  the  under  surface  of  the  middle  peduncle,  with  the 
gray  substance  of  the  cerebellum,  with  the  flocculus,  and  with 
the  gray  matter  at  the  border  of  the  calamus  scriptorus.  The 
nerve  winds  around  the  restiform  body,  from  which  it  receives 
fibres,  and  passes  forward  across  the  posterior  border  of  the 

Fig.  100. 
1  3 

LT  ZI  ZE 

*  LS 

1_5 

Expansion  of  the  Bight  Cochlear  Nerve,  seen  from  the  Base  of  the  Cochlea,  from  a  Laby- 
rinth softened  in  Hydrochloric  Acid.    After  Henk. 

1.  The  branches  entering  through  foramina.  2.  Twig  passing  into  the  modiolus.  3.  Network 
in  the  osseous  lamina  spiralis.  4.  Network  on  its  border.  L,  T.  Labium  tympanicum. 
Z,  I.  Zona  interna.  Z,  E.  Zona  externa  of  the  membrana  basilaris.  L,  S.  Ligamen- 
turn  spirale. 

crus  cerebelli,  in  the  company  with  the  portio  dura,  or  facial 
nerve,  from  which  it  is  partly  separated  by  a  small  artery. 
It  then  passes  into  the  meatus  auditorius  in  company  with 
the  facial  nerve.  At  the  bottom  of  the  internal  auditory  pas- 
sage, in  the  petrous  portion  of  the  temporal  bone,  it  divides 
into  two  branches,  which  are  distributed  to  the  cochlea,  vesti- 
bule, and  semicircular  canals,  and  are  called  the  cochlear  and 
vestibular  branches. 


472  COCHLEA. 

The  auditory  nerve  is  remarkable  for  the  delicacy  of  its 
structure,  which  caused  the  older  anatomists  to  give  it  the 
name  of  portio  mollis.     It  has  only  a  very  thin  neurilemma. 

The  cochlear  nerve  gives  off  a  small  branch,  which  passes 
to  the  vestibular  extremity  of  the  ductus  cochlearis,  and 
through  the  fourth  macula  cribrosa  to  the  partition  wall  of 
the  two  saccules  in  the  vestibule.  From  the  trunk  of  the 
nerve  a  number  of  fine  twigs  arise,  which  pass  through  fora- 
mina direct  to  the  lamina  spiralis  of  the  lower  coil  of  the 
cochlea.  The  remainder  of  the  cochlear  nerve  enters  the 
modiolus,  and  is  divided  into  anastomotic  divisions.  The 
fibres  becomes  separated  from  the  trunk  in  a  line  correspond- 
ing to  the  course  of  the  canalis  spiralis  modioli,  and  permeate 
this  canal.  Here,  by  the  addition  of  ganglion  cells,  they  be- 
come gangliose  striae,  and  finally  end,  at  almost  a  right-angle 
to  the  trunk,  in  the  osseous  lamina  spiralis. 

The  vestibular  nerve,  after  a  slight  gangliose  expansion, 
divides  into  three  branches.  The  upper  passes  through  the 
macula  cribrosa  superior,  and  ends  with  three  branches  on 
the  utricle,  and  on  the  ampulla  of  the  upper  vertical  and  of 
the  horizontal  semicircular  canal.  A  middle  branch  passes 
through  the  middle  macula  cribrosa  to  the  saccule,  while  the 
lower  passes  through  its  own  osseous  canal  to  the  ampulla  of 
the  lower  vertical  semicircular  canal,  and  its  fascicles  are 
loosely  held  together.  Todd  and  Bowman  regard  -it  as  a 
direct  prolongation  of  the  white  matter  of  the  brain. 

In  the  internal  auditory  canal,  the  portio  mollis  forms  a 
connection  with  the  portio  dura  by  means  of  a  few  fascicles  of 
fibres,  which  constitute  what  Wrisberg  called  the  "  portio 
intermedia."  It  is  not  decided  whether  the  connecting  link 
proceeds  from  the  auditory  to  the  facial  nerve,  or  from  the 
latter  to  the  former.  Todd  and  Bowman  believe  it  probable 
that  the  facial  nerve  sends  some  filaments  to  the  blood-vessels 
of  the  labyrinth  and  the  muscular  structure  of  the  internal  ear. 

PERIOSTEUM  OF  THE  LABYRINTH. 

The  periosteum  that  covers  the  walls  of  the  osseous  canal 
is,  with  the  exception  of  that  on  the  outer  wall  of  the  cochlea, 


UTRICLE. 


473 


very  delicate.  Henle*  compares  the  periosteum  of  the  laby- 
rinth to  one  of  the  parts  of  the  choroid,  because  it  is  strewn 
with  nucleated  pigment  cells.  There  are  also  calcareous 
deposits.     It  is  very  difficult,  according  to  Henle,  to  separate 


Fig.  101. 


Fig.  102. 


Periosteum  of  the  Labyrinth.    After . 


Periosteum  of  the  Outer  Wall  of  the  Cochlea. 
After  Henle. 


the  periosteum  of  the  labyrinth,  without  also  detaching  bits  of 
bone.  The  periosteum  is  abundantly  supplied  with  blood- 
vessels. 


UTRICLE  AND  MEMBRANOUS  SEMICIRCULAR  CANALS. 

The  utricle  is  an  elliptical  tube,  situated  on  the  median 
wall  of  the  vestibule.     Its  longest  diameter  corresponds  to  the 

Fig.  103. 


Utricle  and  Membranous  Semicircular  Canals  of  the  Left  Side. 
*  Lelirbuch,  p.  774. 


474 


MEMBRANOUS   SEMICIECULAR   CANALS. 


height  of  the  vestibule.  By  means  of  a  fine  vascular  and 
nervous  network,  and  a  very  delicate  connective  tissue,  it  is 
fastened  to  the  recessus  ellipticus  of  the  vestibule. 

The  membranous  semicircular  canals  are  but  the  lining  of 
the  osseous  canals,  and,  of  course,  of  the  same  shape.  The 
membranous  canals  open  into  the  utriculus  with  five  openings, 
just  as  do  the  osseous  tubes  in  the  vestibule.    At  the  am- 


Fig.  104. 


ffilltll 

MP 

■  ■ 

MmH 

mm 


(vim 


Wall  of  Membranous  Semicircular  Canals. 
1.  Membrana  propria,  artificially  separated  edge.    2.  Epithelium. 

pulla  the  membranous  canal  fills  up  the  osseous  very  com- 
pletely ;  but  there  is  some  space  between  the  other  parts. 
The  walls  of  these  structures  are  transparent,  as  clear  as 
water,  and  of  great  delicacy.  After  the  endolymph  is  re- 
moved, they  fall  together  and  arrange  themselves  in  rigid 
folds.  There  is,  however,  a  point  that  is  firmer,  called  the 
macula  acustica,  situated  on  the  median  wall  of  the  utricle, 
where  a  twig  of  the  auditory  nerve  reaches  this  wall.     The 


MEMBEANOUS   SEMICIKCULAR   CANALS. 


475 


portion  of  the  ampulla  that  contains  the  termination  of  the 
nerve,  and  which  is  detected  by  the  naked  eye  as  a  whitish 
yellow  spot,  is  also  of  firmer  consistency.  This  point  is  called 
the  crista  acustica  by  Max  Schultze.  It  comprises  about  one- 
third  of  the  wall  of  the  ampulla.  It  is  sometimes  surrounded 
by  a  pigmented  line. 

The  wall  of  the  membranous  semicircular  canals  is  from 
0.02mm.  to  0.03mm.  in  thickness,  and  is  composed  of  various 
layers. 


Fig.  105. 


A  Piece  of  the  Wall  of  the  Utricle,  with  the  Otoliths.    After  Eerde. 


The  membrana  propria  is  of  reticulate  and  nuclear  fibrous 
tissue,  of  which  the  periosteum  also  consists.  It  is  perforated 
by  blood-vessels.  There  is  a  basal  membrane  next  the  mem- 
brana propria,  and  on  the  inner  surface  pavement  epithelium. 

The  macula  and  crista  acustica  that  have  been  mentioned, 
are  thickenings  of  the  membrana  propria  caused  by  the  min- 
gling of  connective  tissue,  and  the  ending  of  the  nerves. 

The  otolith  of  the  utriculus  of  the  mammalia  is  a  smooth, 
irregularly  demarcated  and  uneven  mass  of  chalky  white  pow- 
der. It  was  called  otoconia  by  Breschet,  ear-sand  by  Lincke, 
and  ear-crystal  by  Huschke.  The  powder  is  held  together  by 
an  almost  mucous  substance.  The  powder  consists  of  crystals 
of  varying  shape  and  size.  The  largest  are  only  0.012mm. 
long  and  0.008mm.  broad.     They  are  too  small  to  allow  the 


476  DUCTUS  COCHLEAKIS. 

crystal  form  to  be  recognized.  The  material  of  which  otoliths 
is  composed  is  carbonate  of  lime.  Henle  says  it  is  unknown 
how  the  otolith  is  fastened  on  to  the  wall  of  the  utricle. 


SACCULE  AND  DUCTUS  COCHLEARIS. 

The  saccule  is  of  the  shape  of  a  broad  flask  with  a  narrow 
neck.  It  lies  in  the  recessus  sphsericus  of  the  vestibule.  The 
neck  of  this  bottle  or  flask  proceeds  from  the  lower  wall, 
downwards  and  backwards,  and  sinks  into  the  upper  wall  of 
the  vestibular  end  of  ductus  cochlearis,  at  nearly  a  right 
angle,  so  that  a  blind  sac  is  formed  at  the  junction  of  the  two 
parts.  Henle  compares  it  to  the  passage  of  the  oesophagus 
into  the  stomach,  and  of  the  small  intestine  into  the  ccecum. 


THE   DUCTUS    COCHLEARIS.     (Lamina  Spiralis  Membranacea  of 

THE  OLD  ANATOMISTS.) 

The  ductus  cochlearis  begins  with  the  blind  sac  in  the 
vestibule  that  has  been  described,  and  passes  through  the 
whole  cochlea  to  the  apex,  in  which  it  ends  again  as  a  blind 
sac.  The  lower  end  rests  in  the  recessus  cochlearis,  and  the 
upper  in  the  cul-de-sac  of  the  cupola.  The  ductus  cochlearis 
is  attached  on  one  side  to  the  lamina  spiralis  ossea,  and  on 
the  other  to  the  outer  wall  of  the  osseous  cochlear  canal.  On 
a  transverse  section  the  ductus  cochlearis  is  seen  to  be  trian- 
gular in  shape,  and  has,  of  course,  three  walls,  or  sides.  Two 
of  these  walls  diverge  from  the  edges  of  the  lamina  spiralis, 
and  the  other  corresponds  to  the  portion  of  the  cochlear  wall 
to  which  the  insertion  of  the  two  others  is  made.  The  lower 
wall  of  the  ductus  cochlearis,  which  is  turned  towards  the 
scala  tympani  is  called  the  tympanal ;  the  upper,  which  sepa- 
rates the  ductus  cochlearis  from  the  scala  vestibuli,  is  called 
the  vestibular  wall. 

On  the  osseous  border  of  the  lamina  spiralis  is  a  soft  struc- 
ture, only  to  be  seen  in  the  uninjured  specimen  of  the  cochlea, 
which  lengthens  the  lamina  spiralis  towards  the  caliber  of  the 
ductus  cochlearis.  It  is  called  by  Henle  the  limbus  laminae  spi- 
ralis.    (See  Tig.  106.)    It  is  developed  from  the  periosteum  of 


DUCTUS  COCHLEAEIS.  477 

the  lamina  spiralis.  This  structure  gradually  decreases  in 
breadth  and  height  from  the  base  to  the  apex  of  the  cochlea. 
The  edge  of  the  osseous  lamina  recedes  more  and  more  at  the 
same  time  from  the  free  border  of  the  limbus.  This  free  bor- 
der becomes  a  furrow,  called  by  Huschke  the  sulcus  spiralis, 
having,  of  course,  two  lips.  The  upper  lip  is  the  labium  ves- 
tibular ;  the  lower,  the  labium  tympanicum.  The  vestibular 
wall  of  the  ductus  cochlearis  passes  off  from  the  upper  sur- 
face of  the  lamina  spiralis  in  a  line  nearly  corresponding 
to  the  inner  attachment  of  the  limbus  laminae  spiralis,  so 
that  the  latter  is  almost  completely  drawn  into  the  ductus 
cochlearis. 


Fig.  106. 

Lla 


/      /' 


•Sr 


\ 


Transverse  Section  of  a  Cochlear  /Spiral,  from  a  Cochlea  softened  in  Hydrochloric  Add. 

After  Henle. 

The  dotted  lines  indicate  sections  of  the  membrana  tectoria  and  the  auditory  rods.  L  s.  Lamina 
spiralis.  Lis.  Limbus  laminoz  spiralis.  S  v.  Scala  vestibule.  S  t.  Scala  tympani. 
D  c.  Ductus  cochlearis.  L  s  v.  Ligamentum  spirale.  V.  Membrana  vestibularis,  b. 
Membrana  basilaris.  e.  Outer  wall  of  ductus  cochlearis.  *.  Bulging  of  membrana 
basilaris. 

The  upper  surface  of  the  vestibular  lip  of  the  limbus  lamina 
spiralis  is  covered  by  striae,  which  on  front  view  resemble  the 
anterior  surface  of  the  incisor  teeth,  and  hence  Huschke  calls 
them  the  auditory  teeth.  These  furrows,  or  striae,  are  filled 
by  small  rounded  cells.  Their  number  may  run  as  high  as 
2,500.  The  limbus  is  composed  of  connective  tissue,  running 
in  a  radiate  direction  in  the  furrows,  or  striae ;  beneath  these 
furrows  the  connective  tissue  is  reticulate. 

Henle  compares  the  labium  vestibulare  to  a  roof  over  the 
sulcus  spiralis,  and  the  labium  tympanicum  to  a  floor.  Within 


478  DUCTUS  COCHLEAEIS. 

the  labium  tympanicum  run  very  fine  nerve  fibres  from  the 
tissue  of  the  auditory  nerve  to  the  ductus  cochlearis.  The 
labium  tympanicum  consists  of  two  layers,  which  the  nerve 
fibres  fasten  between  them,  and  then  unite  beyond  it  in  a 
sharp  border,  from  which  the  membrana  basilaris  proceeds. 
This  membrana  basilaris,  according  to  Henle,  appears  as  a 
process  of  the  upper  layer  of  the  labium  tympanicum.  There 
is,  however,  a  structure  between  them,  which  corresponds  to 
the  periphery  of  the  nerve  bundles. 

On  the  outer  portion  of  the  upper  surface  of  the  labium 
tympanicum  are  four  radiate  strise,  which  Henle  considers  as 
marks  of  the  nerve  bundles  running  on  the  lower  surface  of 
this  layer.  At  the  periphery  of  these  there  are  other  open- 
ings. 

The  membrana  vestibularis  is  attached  to  the  beginning 
of  the  upper  border  of  the  ridge  of  the  spiral  and  to  the  outer 
cochlear  wall.  There  are  three  layers  in  this  membrane, 
which  by  Kolliker  is  called  Reissner's  membrane.  It  is  epi- 
thelial tissue,  which  in  embryonal  life  seizes  upon  the  vestibu- 
lar side  of  the  cochlear  canal.  This  membrane  has  a  number 
of  blood-vessels. 

The  membrana  basilaris  is  well  shown  in  Fig.  106,  and 
being  the  part  upon  which  rests  the  organ  of  Corti,  has  at- 
tracted very  much  attention  from  anatomists.  It  is  a  con- 
tinuation of  the  labium  tympanicum.  It  gradually  increases 
in  breadth  from  the  base  to  the  apex,  in  the  same  proportion 
that  the  lamina  spiralis  with  its  limbus  decreases  in  size.  Its 
breadth  in  the  newly-born,  in  the  middle  of  the  first  turn  or 
coil  of  the  cochlea,  is  0.17mm. ;  at  the  end  of  the  second, 
0.45.  This  space  is  divided  into  two  parts  or  zones.  The 
inner  was  called  by  Kolliker,  the  habenula  tectu,  and  the 
outer  by  Todd  and  Bowman  the  zona  pectinata.  Henle  gives 
the  two  parts  the  simple  names  of  inner  and  outer  zone.  On 
the  inner  zone  is  found  the  structures  making  up  what  is 
known  as  Corti's  organ,  from  their  discoverer,  Marchese 
Corti.*     The  outer  zone  is  rather  broader  than  the  inner. 

*  Corti  was  formerly  prosector  to  Professor  Joseph  Hyrtl,  and  made  the 
first  exact  microscopic  examination  of  the  lamina  spiralis  ossea,  and  mem- 
branacea. 


DUCTUS  COCHLEARIS.  479 

The  basis  of  the  membrana  basilaris  is  a  structureless 
membrane.  On  the  outer  zone  especially  are  peculiar  knobby 
points.  Upon  this  structureless  membrane  are  the  parts 
known  in  their  totality  as  Corti's  organ.  The  fibres  of  this 
structure  are  arranged  along  the  whole  length  of  the  mem- 
brana basilaris.  There  are  spaces  between  them,  so  that  they 
have  a  certain  resemblance  to  the  keys  of  a  piano. 

The  ligamentum  spirale  is  the  means  of  attaching  the 
membrana  basilaris  to  the  outer  wall  of  the  cochlear  canal. 
The  fibres  of  which  it  is  composed  are  like  those  of  perios- 
teum. 

The  cavity  of  the  ductus  cochlearis  is  divided  into  parts  by 
a  membrane  running  parallel  to  the  membrana  basilaris.  (See 
Kg.  106.)  The  upper  part  is  filled  with  endolymph,  the  lower 
contains  what  Henle  calls  the  terminal  auditory  apparatus. 
The  membrane  which  divides  the  ductus  cochlearis  into  two 
parts  is  called  the  membrana  tectoria  by  Claudius,  but  Corti's 
membrane  by  Kolliker.  The  membrana  tectoria  is  divided 
into  three  zones.  The  middle  zone  is  the  denser  ;  the  inner  is 
structureless  and  has  numerous  openings.  The  outer  zone  is 
made  up  of  a  very  fine  and  friable  network.  It  is  probable, 
according  to  Henle,  that  the  membrana  tectoria  is  firmly  fas- 
tened, and  that  it  is  not  possible  for  it  to  press  closely  upon 
the  parts  covering  it. 


TERMINAL  AUDITORY  APPARATUS. 

Henle  terms  the  important  structures  of  the  lower  chamber 
of  the  ductus  cochlearis  the  terminal  auditory  apparatus. 
They  consist  of  rod-like  bodies,  a  perforated  membrane,  and 
nuclear  cells  of  various  shapes.  A  fourth  part,  whose  exist- 
ence Henle  thinks  is  doubtful,  are  fibres,  in  which  connective 
tissue  and  the  ultimate  fibres  of  the  auditory  nerve  are  found. 


AUDITORY  RODS. 

The  most  important,  physiologically  speaking,  of  this  termi- 
nal apparatus  are  the  auditory  rods,  called  also  Corti's  teeth, 


480 


COETl'S  OEGAN. 


or  Corti's  fibres.  They  are  arranged  in  regular  order,  very  like 
the  cords,  hammers,  or  keys  of  a  piano.  It  is  probably  their 
vibrations  that  cause  us  to  perceive  what  we  call  tones.    There 


Fm.  107. 


100 
1 


From  the  Terminal  Auditory  Apparatus  of  a  Cat.    After  Rente. 
i.  Outer  ends  of  the  inner  fibres,    e.  Outer  fibres.     3.  Outer  covering  cells.    A.  Epithelial  cells. 

are  two  rows  of  these  fibres,  an  inner  and  an  outer.  The  inner 
rods  arise  from  the  membrana  basilaris,  on  which  their  inter- 
nal extremities  are  fastened,  more  or  less  abruptly,  towards 
the  membrana  tectoria,  without,  however,  being  united  to  the 
latter.     The  outer  rods  or  fibres  join,  with  their  inner  extrem- 

Fig.  108. 


Profile  View  of  Outer  and  Inner  Rods. 

B.  Membrana  basilaris  (b),  with  the  terminal  nerve  fibres  (n)  and  the  Inner  and  outer  rods, 
i,  e.    1.  Inner.    2.  Outer  floor  cells.    A.  Attachment  of  the  roof  cells.    ^.Epithelium. 

ities,  the  outer  end  of  the  inner  fibres.  Their  external  ter- 
minations rest  on  the  membrana  basilaris.  There  are  two 
varieties  of  the  inner  row  of  fibres  or  rods ;  one  is  smooth  and 
elliptical  in  shape,  the  other  cylindrical  and  broader  at  each 
end. 

The  outer  row  of  rods  is  cylindrical  in  shape,  and  they 
stand  at  a  greater  distance  apart  than  the  inner.     They  have 


MEMBRANA  RETICULARIS.  481 

a  tortuous  course  sometimes,  like  the  letter  S.  The  inner  row 
of  fibres  is  always  shorter  than  the  outer.  They  join  together 
and  form  a  roof  over  the  inner  zone  of  the  membrana  basil- 
aris.  The  base  of  this  roof  is  0.1mm.  in  breadth.  The  struc- 
ture of  these  rods,  as  shown  by  the  action  of  reagents,  is  a 
tissue  as  hard  as  cartilage. 

Henle  calls  the  terminations  of  the  two  rows  of  rods  upon 
the  membrana  basilaris,  the  lower  extremities ;  and  the  extrem- 
ities which  join  to  make  the  roof,  the  upper  extremities. 


MEMBEANA   RETICULARIS. 

This  is  the  second  of  the  component  parts  of  the  terminal 
auditory  apparatus,  It  arises  from  the  articulation  of  the 
rods  or  fibres,  and  extends  to  the  outer  wall  of  the  cochlea 
parallel  to  the  lamina  basilaris.  It  is  supposed  to  be  a  liga- 
ment to  bind  the  rods  together.  The  tissue  of  the  lamina 
reticularis  is  not  less  firm  than  that  of  the  rods,  but  it  is 
delicate. 

AUDITORY   CELLS. 

These  are  cylindrical  and  spherical  elements  which  are 
called  cells,  because  they  contain  nuclei.  They  may  be  con- 
sidered, according  to  Henle,  as  epithelial  or  ganglion  cells. 
Some  of  these  cells  are  called  hair  cells,  stachel  cells,  and 
in  them  are  probably  the  terminal  filaments  of  the  cochlear 
nerve. 

Henle  divides  these  cells  which  are  not  epithelial  into  two 
classes  :  the  roof-cells  (deck-zellen),  and  floor-cells  (boden- 
zellen).  Gottstein  calls  these  hair  cells.  The  roof-cells  are 
found  on  the  convex  side  of  the  roof  formed  by  the  union  of 
the  two  rows  of  arches. 

The  floor  cells  are  found  at  the  angle  which  the  base  of 
each  rod  makes  with  the  membrana  basilaris. 

Henle  divides  the  floor  cells  into  three  varieties  :  an  inner, 
an  outer,  and  a  lower  outer. 

After  the  exit  of  the  nerve  fibres  from  the  canals  of  the 
31 


482 


AUDITOEY  CELLS. 


labium  tympanicum,  the  bundles  of  nerve  fibres  take  two 
different  directions.  One  part  maintains  the  original  radiate 
direction,  the  other  proceeds  spirally.  These  fibres  take  dif- 
ferent directions  with  reference  to  the  fibres  of  Corti ;  at  the 


Fig.  109. 


Diagrammatic  Bepresentation  of  the  Terminal  Auditory  Apparatus.    After  Eenle. 

a.  Teeth  of  the  labium  vestibulare,  b.  Epithelial  cells  of  the  labium  tympanicum.  c.  Open- 
ings of  these  cells.  A.  Inner  rods.  e.  Outer  rods.  f.  Connecting  fibres,  g,  h,  i,  k,  k'. 
First  to  fourth  bundle  of  spiral  nerve  fibres.  I.  Radiate  bundles,  m.  Upper  nerve  roof 
cells,  n.  Epithelial  cells,  o.  Supporting  fibres  of  rods.  p.  Radiate  nerve  fibres  vpon 
membrana  basilaris.  q.  Nerve  fibre  running  above  rods.  u.  Membrana  basilaris.  x. 
Upper  outer  roof  cells,    y.  Lower  and  outer  roof  cells. 


apex  of  the  cochlea  they  decrease  in  number.  They  do  not 
lie  directly  upon  the  membrana  basilaris,  but  at  a  certain 
height  above  it.      The  nerve  fibres  are  probably  connected 


ANATOMY  OP  INTERNAL  EAR — AUTHORITIES.  483 

with  the  cells  at  the  base  of  the  rods,  the  so-called  floor  cells 
of  Henle.  It  is  possible  that  they  are  also  connected  to  the 
lower  sharp  extremities  of  the  upper  and  outer  roof  cells. 

BLOOD-VESSELS. 

The  blood  passes  to  the  internal  ear  through  the  auditiva 
interna  artery,  which  is  a  branch  of  the  basilar,  according  to 
Hyrtl.  The  basilar  conies  from  the  vertebral  and  the  verte- 
bral from  the  subclavian.  After  the  internal  auditory  artery 
has  entered  into  the  meatus  auditorus  internus,  it  divides  into 
a  vestibular  and  cochlear  branch.  The  cochlear  branch  di- 
vides in  numerous  branches  which  pass  through  the  foramina 
of  the  tractus  spiralis  foraminulentus  into  the  modiolus,  and 
then  go  on  between  the  layers  of  the  lamina  spiralis,  and  are 
finally  lost  in  the  spirals  of  the  cochlea.  The  vestibular  artery 
passes  through  the  posterior  wall  of  the  vestibule  in  numerous 
fine  twigs  to  the  soft  structures  of  the  vestibule  and  semicir- 
cular canals.  The  stylo-mastoid  artery  is  said  to  give  several 
small  branches  to  the  labyrinth.  It  is  important  to  observe 
the  fact  to  which  Von  Troltsch  calls  attention — that  the  blood 
supply  of  the  labyrinth  and  of  the  middle  ear  are  nearly 
separate  and  independent  of  each  other.  This  may  explain 
the  relative  infrequency  of  the  extension  of  disease  of  the 
middle  ear  to  the  internal  ear. 


AUTHOEITIES. 

Soettcher,  Arthur,  Professor  in  Dorpat.  Kritische  Bemerkungen  und  neue 
Beitrage  zur  Literatur  des  Gehorlabyrinths.     Dorpat,  1872. 

Goltz,  quoted  by  Brunner  and  Knapp,  Archives  for  Ophthalmology  and  Oto- 
logy, vol.  ii.,  No.  1. 

Gottstein,  J~.  Ueber  den  feineren  Bau  und  die  Entwicklung  der  Gehor- 
schencke  beim  Menschen  und  dem  Saugethieren.  Bonn,  Max  Cohen  & 
Sohn. 

Gray,  Henry.  Anatomy,  Descriptive  and  Surgical.  Reprint.  Philadelphia, 
1862. 


484  ATJTHOKITTES. 

Gruber,  Josef.    Lehrbuch  der  Ohrenheilkunde.    Wien,  1870. 

ffenle,  J~.  Handbuch  der  systematischen  Anatomie  des  Mensclien.  Braun- 
schweig, 1866. 

Byrtl,  Joseph.    Anatomie  des  Menschen,  7  Auflage.    Wien,  1862. 

J~ones,  Wharton.    Cyclopaedia  of  Anatomy  and  Physiology,  vol.  ii. 

Todd,  Robert  Bentley,  and  Bowman,  William.  The  Physiological  Anatomy 
and  Physiology  of  Man.    Reprint.     Philadelphia,  1857. 

Waldeyer,  W.*  In  Strieker's  Handbook.  Translated  by  Albert  H.  Buck. 
New  York,  1872. 

*  The  best  bibliography  of  the  Anatomy  of  the  internal  ear,  is  found  in 
Waldeyer's  article. 


CHAPTER    XIX. 

DISEASES  OF  THE  INTERNAL  EAR. 

Nervous  deafness  may  be  defined  to  be  a  primary  affec- 
tion of  the  auditory  nerve  or  labyrinth,  or  of  both.  It  should 
be  carefully  distinguished  from  other  forms  of  impaired  hear- 
ing that  are  accompanied  by  symptoms  of  general  nervous 
disease,  or  by  evidences  of  secondary  affections  of  the  laby- 
rinth, such  as  vertigo  and  tinnitus  aurium. 

Primary  and  independent  affections  of  the  labyrinth  or 
internal  ear  are  happily  the  most  infrequent  of  aural  diseases. 
"We  know  very  little  of  the  nature  of  these  affections,  and  we 
have  as  yet  absolutely  no  means  of  treatment  for  them  that 
can  be  said  to  be  at  all  successful.  The  gaps  in  our  knowl- 
edge on  this  subject  are  yet  to  be  filled  up  by  the  patient 
comparison  of  symptoms  with  post-mortem  appearances.  Of 
fifteen  hundred  cases  of  aural  disease  observed  by  the  author 
in  private  practice,  but  fifty-seven  could  be  fairly  considered 
to  be  cases  of  primary  disease  of  the  internal  ear.  The 
statistics  of  most  other  writers,  and  the  reports  of  public  insti- 
tutions show  about  the  same  proportions ;  Yoltolini,*  however, 
believes  that  affections  of  the  labyrinth  are  more  common 
than  is  usually  believed,  but  his  opinions  are  as  yet  not  sup- 
ported by  the  only  reliable  evidence,  that  which  has  been  just 
alluded  to,  the  confirmation  on  the  post-mortem  table  of  symp- 
toms observed  during  life. 

It  has  been  already  said  in  this  volume,  that  it  is  quite  a 
common  view  that  nervous  affections  of  the  ear  are  very  fre- 
quently met  with.  The  kind  of  nervous  affection  that  is 
meant  by  the  laity  and  those  members  of  the  profession  who 

*  Von  TrSltsch,  Translation,  2d  American  Edition,  p.  498. 


486  NERVOUS  DEAFNESS. 

entertain  this  notion  is  quite  different,  however,  from  the  dis- 
eases of  the  nerve  apparatus  now  under  discussion.  When  a 
patient  is  debilitated  and  unstrung,  unsteady  in  muscular 
movement,  anxious  and.  despondent,  and  is  at  the  same  time 
affected  with  a  chronic  affection  of  the  middle  ear,  he  is  often 
supposed  to  have  a  nervous  disease  of  the  ear.  It  is  quite 
doubtful,  however,  if  in  such  cases  the  nerves  of  the  ear  are  at 
all  affected.  There  are  certainly  no  symptoms  of  derange- 
ment of  the  auditory  nerve,  in  the  general  debility,  unsteadi- 
ness, and  anxiety  that  are  popularly  denominated  nervousness. 
Affections  of  the  auditory  nerve  make  the  subjects  deaf,  and 
sometimes  cause  them  to  stagger  in  their  gait,  but  they  do 
not  render  them  nervous  or  unsteady  in  the  ordinary  accepta- 
tion of  that  term.  Besides,  it  cannot  be  said  that  nervous 
people  are  especially  liable  to  deafness  from  lesions  of  the 
labyrinth,  any  more  than  they  are  to  atrophy  of  the  optic 
nerve.  On  this  point  Mr.  Hinton*  says,  that  it  is  difficult  for 
him  to  accept  debility,  nervous  or  other,  as  a  cause  of  nervous 
deafness.  He  has  not  found  that  the  cases  of  deafness  which 
appear  to  him  as  properly  classed  among  the  nervous  ones, 
occur  specially  in  the  debilitated.  I  am  thus  detailed  upon  this 
subject  of  nervous  deafness,  because  there  is  so  much  error 
in  the  understanding  of  what  nervous  deafness  really  is,  and 
because  this  error  leads  to  a  confusion  of  that  common  affec- 
tion, chronic  non-suppurative  affection  of  the  middle  ear,  with 
the  comparatively  rare  affection,  disease  of  the  labyrinth.  It  is 
probable,  however,  that  secondary  disease  of  the  labyrinth — 
that  is,  disease  extending  to  this  part  from  the  middle  ear — is 
quite  frequent.  We  know  at  least  that  affections  of  the  fenes- 
tra ovalis,  or  undue  pressure  of  the  chain  of  bones  upon  this 
opening  into  the  vestibule,  will  cause  vertigo,  nausea,  and 
other  head  symptoms.  Post-mortem  examinations  also  show 
that  changes  in  the  labyrinth  are  apt  to  occur  in  connection 
with  chronic  diseases  of  the  middle  ear,  even  when  there  is  no 
suppuration  or  caries,  when,  as  we  have  seen,  the  labyrinth  is 
sometimes  necrosed  and  exfoliated.  Young  children  who  suf- 
fer from  acute  inflammations  of  the  middle  ear,  in  consequence 

*  Nervous  Deafness.    Keprint  from  Guy's  Hospital  Reports,  1867. 


NERVOUS  DEAFJNESS.  487 

of  tlie  exanthemata,  very  readily  develop  head  symptoms, 
which  undoubtedly  depend  upon  extension  of  the  middle  ear 
disease  through  the  very  delicate  partition  walls  separating 
the  cavity  of  the  tympanum  from  the  brain,  or  through  the 
wall  that  separates  it  from  the  expansion  of  the  cerebrum  that 
we  call  the  internal  ear ;  but  these  cases  of  secondary  affec- 
tion of  the  labyrinth  are  reached  by  treatment  of  the  primary 
affection  of  the  middle  ear,  and  it  will  not  be  proper  to  include 
them  in  this  chapter. 

Yoltolini  is  quite  positive  that  there  is  a  primary  affection 
of  the  labyrinth  that  is  sometimes  mistaken  for  cerebro-spinal 
meningitis,  and  he  has  written  several  papers,*  illustrated 
by  cases,  to  sustain  his  position.  Although  his  ideas  have 
been  rejected  by  some  other  writers,  I  do  not  think  the  ques- 
tion can  be  at  all  considered  as  a  settled  one.  After  a  careful 
consideration  of  the  history  of  very  many  cases  of  supposed 
cerebro-spinal  meningitis  occurring  in  young  children,  the 
suspicion  is  at  least  a  strong  one  in  my  mind  that  Voltolini  is 
correct  in  this  view,  and  that  an  affection  of  the  labyrinth  may 
occur  in  young  children,  and  be  erroneously  supposed  to  be 
cerebro-spinal  meningitis.  Unfortunately — although  we  have 
had  an  epidemic  of  cerebro-spinal  meningitis  in  New  York — I 
have  as  yet  had  no  opportunity  of  studying  this  disease  except 
from  its  clinical  history,  when  the  victims  were  brought  to  me 
deaf  or  blind. 

After  these  general  observations  as  to  the  nature  of  so- 
called  nervous  deafness,  or  of  what  should  be  termed  dis- 
eases of  the  internal  ear,  we  may  enter  upon  the  consideration 
of  the  symptoms,  causes,  pathology  and  treatment  of  affections 
of  the  auditory  nerve  and  its  expansions  in  the  labyrinth. 

Symptoms. — There  is  but  one  symptom  that  is  absolutely 
pathognomonic  of  disease  of  the  auditory  nerve,  and  that  is 
absolute  deafness.  We  may,  it  is  true,  have  mere  impairment 
of  the  hearing,  and  yet  find  disease  of  the  labyrinth ;  but  if 
the  deafness  is  absolute,  or  nearly  so,  we  must  conclude  that 
the  essential  part  of  the  organ  of  hearing  is  invaded.     It  is  a 

*  Monatsschrift  fur  Ohrenheilkunde,  Bd.  I.  and  VI. 


488  DISEASES  OF  INTERNAL  EAE — SYMPTOMS. 

very  rare  thing  indeed,  that  the  impairment  of  hearing  from 
disease  of  the  middle  ear  becomes  so  profound  that  words 
spoken  into  the  ear  through  a  tube  cannot  be  distinguished ; 
but  in  many  of  the  cases  of  deafness  from  cerebro-spinal  menin- 
gitis, from  fevers,  from  apoplexy  of  the  labyrinth,  from  inju- 
ries, no  words,  however  conducted  to  the  ear,  can  be  made  out 
by  the  patient,  and  actual  deafness,  not  merely  great  impair- 
ment of  hearing,  exists.  The  auditory  nerve  may  have  some 
perception  of  sound  in  these  latter  cases ;  but  these  percep- 
tions can  only  be  compared  to  the  flashes  of  light  seen  by 
amaurotic  patients.  Other  symptoms  of  nerve  deafness,  such 
as  vertigo,  nausea,  vomiting,  tinnitus  aurium,  are  also  seen  in 
affections  of  the  middle  ear,  although  very  few  cases  of  nau- 
sea or  vomiting  occur,  unless  the  nerve  expansion  in  the  laby- 
rinth is  involved.  A  staggering  gait,  or  loss  of  equilibrium,  is 
also  a  symptom  of  nerve  deafness  ;  at  least  patients  who  re- 
cover from  cerebro-spinal  meningitis,  with  deafness,  exhibit 
this  symptom,  and  the  same  is  true  of  those  who  become  pro- 
foundly deaf  in  an  instant,  and  whose  history  shows  that  they 
have  had  a  primary  affection  of  the  labyrinth. 

After  these  symptoms  have  been  considered,  the  tuning- 
fork  becomes  very  valuable  as  a  means  of  diagnosis  in  sus- 
pected nerve  deafness.  As  we  have  seen  in  Chapter  II.,  the 
tuning-fork  is  heard  more  distinctly  if  the  ears  be  stopped  with 
the  finger  or  the  like,  while  the  handle  is  placed  upon  the  fore- 
head or  teeth.  If  a  person  be  affected  with  nerve  deafness,  it 
is  a  clinical  fact  that  such  a  stoppage  of  the  meatus  does  not 
usually  at  all  intensify  the  sound  of  the  tuning-fork.  Of  course 
there  are  no  appearances  upon  the  drum-head  or  in  the  Eusta- 
chian tube,  that  give  evidence  of  disease  of  the  lab}7rinth.  We 
may  have  a  normal  membrana  tympani  in  cases  where  we  feel 
sure  from  other  evidences  that  the  auditory  nerve  is  the  seat 
of  the  disease  ;  and  we  may,  as  I  have  often  had  occasion  to 
observe,  especially  in  deafness  from  cerebro-spinal  meningitis, 
find  a  sunken  drum-head  and  other  marks  of  chronic  processes 
in  the  middle  ear,  which  have  occurred  secondarily  to,  or  in  con- 
nection with,  an  affection  of  the  labyrinth.  The  one  prominent 
symptom,  however,  in  most  cases  of  true  disease  of  the  audi- 
tory nerve,  is  sudden  and  complete  deafness.     Yet  it  must  not 


DISEASES  OF  INTERNAL  EAR — SYMPTOMS.  489 

be  supposed  that  the  deafness  is  always  absolute.  I  lately  saw 
a  case  which  has  led  me  to  the  belief  that  we  may  have  an  affec- 
tion of  the  labyrinth,  as  sudden  in  its  origin  as  those  in  which 
the  patients  awake,  as  they  sometimes  do,  to  find  themselves 
totally  deaf  of  one  ear,  and  yet  the  hearing  be  merely  impaired. 
I  confess,  however,  that  it  is  hard  to  conceive  of  a  sudden  effu- 
sion into  the  semicircular  canals  and  cochlea,  which  should  be 
so  circumscribed  as  to  make  the  patient  but  partially  deaf. 
The  case  in  question  is  as  follows :  A  physician,  set  33,  states 
that  while  a  student,  in  1869,  he  was  one  day  studying  in  a 
recumbent  position  upon  a  lounge,  and  when  he  got  up  he  was 
dizzy  and  fell  down  at  once.  He  did  not  become  unconscious, 
but  he  found  that  he  had  a  ringing  in  his  left  ear.  He  tested 
his  hearing  by  means  of  the  watch,  and  found  that  it  was 
greatly  impaired.  From  that  time  to  this  he  has  always  had 
a  ringing  in  his  ear,  with  impairment  of  hearing.  The  tuning- 
fork  was  heard  better  in  the  sound  ear.  The  hearing  distance 
was — Eight  ear,  f  f  ;  left  ear,  |-|.  The  drum-head  was  a  little 
sunken,  and  the  light  spot  was  small.  Air  entered  both  Eu- 
stachian tubes.  There  was  no  improvement  after  inflation  of 
the  ears.  The  patient,  who  was  a  careful  physician,  was  con- 
fident that  he  never  before  had  any  disease  of  the  ears.  He 
stated  also  that  he  became  much  worse,  as  to  the  ringing, 
when  overworked  or  fatigued  from  any  cause.  I  am  not  ready 
to  affirm  that  this  is  a  true  case  of  primary  affection  of  the 
labyrinth ;  but  it  seems  to  me  that  this  is  probably  the  case. 

Deafness  to  certain  tones  must  of  necessity  be  due  to  some 
affection  of  the  cochlea,  and  this  is  an  affection  sometimes 
seen,  as  has  been  known  since  the  experiments  of  Wollaston, 
who  found  that  some  persons  were  unable  to  hear  the  chirping 
of  a  cricket,  which  is  the  highest  tone  known.  If  we  accept 
the  theory  of  Helmholtz,  that  Corti's  organ  in  the  labyrinth  is 
a  resonance  apparatus,  and  that  individual  fibres  of  the  audi- 
tory nerve  in  the  cochlea  are  tuned  for  certain  notes,  the  patho- 
logy of  such  cases  becomes  clear.  It  should  be  remembered, 
however,  that  this  symptom,  as  well  as  double  hearing,  like 
tinnitus  aurium,  may  be  merely  secondary  to  an  affection  of 
the  middle  ear,  which  causes  pressure  and  hyperemia  of  .the 
cochlea.     Indeed,  double  hearing,  or  the  hearing  of  the  last 


490  DOUBLE  HEARING. 

tones  or  syllables  repeated  or  echoed,  is  usually  a  secondary 
symptom  of  middle-ear  disease.  It  lias  been  observed  by  Sir 
Everard  Home,*  Gruber,t  Moos,!  and  Knapp.§  In  Knapp's 
case,  which  occurred  in  a  patient  suffering  from  acute  aural 
catarrh,  the  patient  heard  all  sounds  of  the  three  upper  octaves 
double.  Both  ears  of  this  patient  were  affected  with  this 
double  hearing.  This  trouble  increased  until  "all  musical 
sounds  appeared  to  him  perverse,  and  music  in  general,  which 
he  had  liked  passionately,  became  a  perfect  horror  to  him." 

The  explanation  of  these  cases,  as  has  been  already  inti- 
mated, is  to  be  found  in  a  change  in  the  pressure  upon  the 
fluid  in  the  labyrinth,  and  thus  the  ends  of  the  nerve  fibres 
are  incorrectly  tuned.  It  is  hardly  necessary  to  more  than 
allude  to  the  symptom  of  tinnitus  aurium  in  primary  disease 
of  the  labyrinth.  It  scarcely  differs  from  the  sounds  heard 
by  those  who  suffer  from  chronic  non-suppurative  inflamma- 
tion, although  in  many  cases  of  total  deafness  no  tinnitus 
exists.  We  may  then  believe  that  the  function  of  the  nerve  is 
completely  destroyed. 

Pain  is  not  usually  a  symptom  of  disease  of  the  nerve, 
except  in  the  form  which  Yoltolini  calls  inflammation  of  the 
membranous  labyrinth.  In  these  cases  it  may  exist.  Nausea, 
vomiting,  and  convulsions,  as  well  as  opisthotonos  and  deli- 
rium, may  be  symptoms  of  labyrinth  disease,  as  well  as  of 
cerebro-spinal  meningitis  and  of  acute  catarrh  of  the  middle 
ear. 

The  symptoms  of  inflammation  of  membranous  labyrinth 
that  has  been  mistaken  for  cerebro-spinal  meningitis,  should  be 
carefully  considered  in  order  that  the  practitioner  may  be  able 
to  clear  up  the  doubts  which  have  been  thrown  upon  the  exist- 
ence of  this  disease.  Gruber  ||  unites  with  me  in  believing  that 
such  a  disease  may  occur.  If  we  find  a  child  suddenly  taken 
with  severe  vomiting,  followed  by  stupor  or  delirium,  who 
never  has  any  paralysis,  but  slight  opisthotonos,  such  as  chil- 

*  Transactions  of  Royal  Society,  1800. 

+  Lehrbuch,  p.  626. 

%  Klinik  der  Ohrenkrankheiten,  p.  319. 

§  Transactions  of  the  American  Otological  Society,  1871. 

||  Lehrbuch,  p.  552. 


Meniere's  cases.  491 

dren  have  with  acute  otitis  media,  and  if  we  see  this  child 
recover  in  a  few  days  from  every  symptom  except  the  one  of 
absolute  deafness  and  a  staggering  gait,  I  think  it  is  more  rea- 
sonable to  think  of  an  affection  of  the  ear  as  the  cause  of  these 
symptoms,  than  of  a  disease  of  the  brain  and  spinal  cord. 

Having  seen  many  cases  in  which  such  a  history  was  clearly 
given,  I  must  believe  in  a  primary  acute  inflammation  of  the 
labyrinth,  and  I  trust  the  attention  of  physicians  will  be 
directed  to  the  differential  diagnosis  between  this  affection 
and  cerebro-spinal  meningitis. 

The  late  Dr.  P.  Meniere,  of  Paris,  published  several  obser- 
vations of  cases  of  loss  of  equilibrium  accompanied  by  deaf- 
ness, which  have  very  improperly  led  to  the  classification  of  a 
large  class  of  different  forms  of  disease  of  the  labyrinth  under 
the  head  of  Meniere's  disease.  These  cases  have  the  usual 
history  of  what  we  may  suppose  to  be  effusion  into  the  laby- 
rinth— that  is,  nausea,  vomiting,  vertigo,  and  inability  to  walk 
straight,  with  sudden  deafness.  There  was  an  autopsy  in  one 
case,  which  has  been  repeatedly  quoted.  This  case,  however, 
was  not  a  true  specimen  of  the  cases  from  the  clinical  history 
of  which  Meniere  made  his  diagnoses.  It  was  that  of  a 
young  woman  who,  while  menstruating,  caught  cold  and  be- 
came suddenly  deaf.  Her  chief  symptoms  were  vertigo  and 
frequent  vomiting.  Dr.  Meniere  examined  the  ears  and  found 
all  the  parts  healthy  except  the  semicircular  canals,  which 
were  filled  with  a  reddish  plastic  substance  replacing  the 
labyrinth  fluid.  The  vestibule  also  exhibited  traces  of  this 
exudation,  but  the  cochlea,  brain,  and  spinal  cord  were  normal. 
The  subject  of  the  occurrence  of  these  symptoms  and  the 
cases  reported  by  Meniere,  especially  the  one  accompanied 
by  a  post-mortem,  are  indeed  important,  but  it  seems  to  me 
a  mistake  to  classify  symptoms  of  effusions  into  the  labyrinth, 
from  whatever  cause,  under  such  a  name  as  Meniere's  disease, 
and  to  infer  that  lesion  of  the  semicircular  canals  only  is  to  be 
found  in  such  cases. 

In  recapitulation,  it  may  be  said  that  the  chief  symptoms 
of  labyrinth  disease  are — 

Deafness,  usually  nearly  absolute,  and  occurring  suddenly. 

Yertigo. 


492  ELECTRICITY  IN  DIAGNOSIS. 

Nausea  and  vomiting. 
Loss  of  equilibrium. 

Inability  to  hear  the  tuning-fork   more  distinctly  in  the 
affected  ear. 


ELECTEICITY  IN   THE  DIAGNOSIS  OF  DISEASE  OP   THE  AUDI- 
TORY  NERVE. 

Electricity  has  been  much  used  in  the  diagnosis  of  disease 
of  the  auditory  nerve,  and  some  authorities  believe  that  we 
have  a  positive  means  of  diagnosis  in  the  employment  of  the 
galvanic  current.  My  friend,  Dr.  Roger  S.  Tracy,  has  taken 
the  pains  to  go  over  the  literature  which  I  have  collected 
upon  this  subject  for  me,  with  a  view  to  the  determination  of 
the  side  on  which  lays  the  weight  of  evidence  as  to  the  reac- 
tion of  the  auditory  nerve  under  galvanism.  The  method  of 
using  the  current  should  be  first  described. 

The  galvanic  current  is  applied  to  the  middle  and  internal 
ear  by  means  of  an  electrode  insulated  to  the  end,  introduced 
into  the  external  auditory  canal  (which  has  been  previously 
filled  with  warm  water),  until  it  touches  the  membrana  tym- 
panum, or  is  firmly  pressed  against  the  tragus,  the  other  elec- 
trode being  held  in  the  hand  of  the  opposite  side.  The  second 
electrode  may  also  be  introduced,  through  a  catheter,  into  the 
Eustachian  tube,  and  even  into  the  cavity  of  the  tympanum, 
as  by  Wreden,  of  St.  Petersburg. 

When  the  galvanic  current  is  passed  through  the  ear  in  this 
manner,  certain  sounds  are  heard  by  the  patient,  described  as 
hissing,  roaring,  ringing,  etc.,  which  have  been  formulated  by 
Brenner,  who,  after  a  long  series  of  careful  observations,  has 
established  a  formula  for  the  reaction  in  the  normal  ear,  which 
he  claims  to  be  constant.  He  has  also  determined  formulae 
for  some  diseased  conditions.  Brenner  and  his  followers  hold 
that  these  acoustic  phenomena  are  all  due  to  a  direct  irrita- 
tion of  the  auditory  nerve  by  the  current,  while  others  have 
considered  the  irritation  to  be  reflex,  through  the  medium  of 
the  trigeminus.  It  is  not  claimed  that  the  faradic  (induced) 
current  produces  these  effects,  or  at  least  not  to  the  same 
degree  as  the  galvanic  current. 


ELECTRICITY  IN  DIAGNOSIS.  493 

Dr.  Hagen,  of  Leipsic,  in  an  able  monograph,*  takes  strong 
ground  in  support  of  Brenner,  and  thinks  the  following  points 
may  be  considered  established  : 

1st.  That  the  auditory  nerve  reacts  to  the  galvanic  current. 

2d.  Through  the  galvanic  irritation  of  this  nerve,  we  can 
learn  its  condition,  which  we  cannot  learn  in  any  other  way. 

3d.  With  this  assistance  we  can  with  certainty  diagnosti- 
cate a  perforation  of  the  drum-head. 

4th.  The  passage  of  the  current  through  a  diseased  ear 
informs  us  whether,  in  addition  to  visible  changes  in  the 
organ,  the  nerves  are  also  affected. 

5th.  That  when,  with  subjective  symptoms  of  tinnitus,  etc., 
the  galvanic  reaction  indicates  hyperesthesia  of  the  nerve,  it 
is  in  some  cases  possible  to  abolish  these  sensations  perma- 
nently, or  for  a  time. 

Dr.  Wreden,  of  St.  Petersburg,!  on  the  other  hand,  by  a 
series  of  carefully  conducted  experiments  upon  sound  and 
unsound  ears,  claims  to  have  established  the  fact  that  the 
sounds  heard  in  the  ear  during  the  passage  of  the  electrical 
current,  are  due  to  the  contraction  of  the  small  muscles  of  the 
middle  ear,  and  not  to  the  direct  or  reflex  irritation  of  the 
auditory  nerve,  as  Brenner  and  others  have  asserted. 

He  has  used  for  these  observations  small  sounds,  one  of 
which,  for  what  he  calls  tubal  electrization,  is  introduced, 
through  the  catheter,  the  Avhole  length  of  the  Eustachian  tube, 
and  the  other,  for  middle  ear  electrization,  projects  two  milli- 
metres into  the  cavity  of  the  tympanum,  being  insulated 
throughout  the  portion  lying  in  the  tube.  These  electrodes, 
for  greater  accuracy  in  their  introduction,  have  each  three 
marks  upon  them ;  one  indicating  the  exact  length  of  the  cathe- 
ter through  which  the  electrode  is  introduced,  the  second,  24 
millimetres  from  the  first,  the  length  of  the  cartilaginous  por- 
tion of  the  Eustachian  tube,  and  the  third,  11  millimetres  from 
the  second,  the  situation  of  the  tympanic  extremity  of  the  tube 
in  adults. 

By  tubal  electrization  he  claims  to  irritate  the  fifth  nerve, 

*  Praktische  Beitrage  zur  Okrenheilkunde.     Leipsic,  1866. 
f  Beitrage  zur  Begriindung  einer  Lebre  liber  die  electrisclie  Beizung  der 
Biunenmuskeln  des  Ohres. 


494  ELECTRICITY  IN  DIAGNOSIS. 

and  produce  contractions  of  the  tensor  tympani,  and  by  middle 
ear  electrization,  the  seventh,  or  facial  nerve,  with  consequent 
contractions  of  the  stapedius. 

In  view  of  the  importance  of  his  researches,  it  may  be  well 
to  give  here  some  of  the  proofs  which  he  adduces  in  support 
of  his  position. 

1st.  During  the  passage  of  the  galvanic  or  faradic  cur- 
rent, by  means  of  tubal  electrization,  an  inspection  of  the  ineni- 
brana  tympani  will  show  a  decided  drawing  inwards  of  the 
membrane,  at  the  opening  and  closing  of  the  circuit.  This 
motion  of  the  drum-head  is  accompanied  by  a  sound  readily 
appreciable  by  the  otoscope. 

2d.  At  the  same  time  with  these  objective  phenomena,  the 
patient  feels  an  evident  contraction  in  the  ear,  which  an  edu- 
cated person  always  refers  to  the  membrana  tympani. 

3d.  By  the  second  method  of  electrization,  an  insulated  elec- 
trode in  the  middle  ear,  a  sensation  as  of  a  powerful  blow  is 
felt  in  the  ear,  accompanied  by  giddiness  and  faintness. 

4th.  He  has  observed  a  case  of  clonic  spasm  of  the  stape- 
dius muscle,  in  which  every  muscular  contraction  was  accom- 
panied by  sensations  and  sounds  precisely  similar  to  those 
produced  during  the  passage  of  the  electrical  current. 

5  th.  Even  the  adherents  of  the  theory  of  direct  irritation 
of  the  auditory  nerve  acknowledge  that  no  current  will  pro- 
duce sounds  in  healthy  ears,  unless  it  is  strong  enough  to 
excite  contractions  of  the  muscles  supplied  by  the  facial  nerve. 
In  this  conditio  sine  qua  non  is  included,  of  course,  the  contrac- 
tion of  the  stapedius. 

6th.  He  has  repeatedly  had  opportunity  to  observe,  that  in 
cases  of  complete  facial  paralysis,  in  which  a  simultaneous 
paralysis  of  the  auditory  nerve  could  be  excluded,  even  the 
strongest  currents  failed  to  produce  any  sensation  of  sound, 
either  by  tubal  electrization  or  by  the  external  meatus.  This 
complete  absence  of  result  in  such  cases  is  inexplicable  upon 
the  theory  of  irritation  of  the  auditory  nerve. 

7th.  The  well-known  fact  of  the  absence  of  sounds  dur- 
ing the  passage  of  the  current,  in  some  persons  whose  ears 
are  diseased,  but  whose  auditory  and  facial  nerves  are  healthy, 
can  be  explained  by  immobility  of  the  stapes  (from  anchylo- 


ELECTRICITY  IN  DIAGNOSIS.  495 

sis  or  other  cause),  while  on  Brenner's  theory  it  is  inexpli- 
cable. 

8th.  The  absence  of  all  sensations  of  sound  during  tubal 
electrization,  where  the  membrana  tympani  is  destroyed,  and 
both  incus  and  malleus  gone,  as  in  a  case  reported  by  Wreden,* 
is  likewise  difficult  to  explain  on  Brenner's  theory. 

Drs.  Erb  and  Moos,  of  Heidelberg,  adhere  to  the  theory  of 
Brenner,  and  the  former  has  written  a  monograph  in  its 
support.f 

Schwartze,  of  Halle,  and  others  equally  eminent  as  observ- 
ers, dispute  Brenner's  conclusions. 

The  questions  at  issue  cannot  yet  be  considered  settled, 
though  the  stronger  arguments  at  present  appear  to  favor  the 
theory  of  muscular  contraction. 

I  beg  to  refer  those  who  are  interested  in  Brenner's  for- 
mula to  the  article  upon  aural  disease  in  Beard  and  Rockwell's 
treatise  on  electricity.:}: 

Dr.  C.  J.  Blake,§  who  is  a  believer  in  the  theory  that  the 
auditory  nerve  is  actually  excited  by  galvanization  after  the 
method  of  Brenner,  has  sought  some  other  means  of  demon- 
stration of  the  condition  of  the  auditory  nerve,  than  the  ability 
to  obtain  a  certain  formula,  which,  as  even  the  advocates  of 
Brenner's  theories  admit,  sometimes  does  not  exist.  He  finds 
that  "  the  passage  of  the  galvanic  current  increases,  not  only 
the  limit  of  perception  of  musical  tones,  but  also  the  intensity 
of  perception,  the  degree  of  increase  in  intensity  of  perception 
being  a  measure  of  the  degree  in  which  the  auditory  nerve 
responds  to  the  stimulus."  The  following  case,  given  by 
Dr.  Blake  in  the  article  from  which  I  have  quoted,  will  give 
his  views  as  to  the  value  of  this  method  of  determining  the 
state  of  the  auditory  nerve. 

"A  man  thirty -two  years  of  age,  first  noticed  diminution  of  hearing  and  a 
rushing  sound  in  both  ears,  ten  years  before  the  date  of  his  application  for 
treatment.  His  general  health  had  been  good  with  exception  of  occasional 
attacks  of  malarial  fever,  for  relief  from  which  he  had  used  quinine  in  large 

-  *  Op.  cit.,  p.  33. 
\  Archives  of  Ophthalmology  and  Otology,  vol.  I.,  No.  1,  1869. 
%  Medical  and  Surgical  Uses  of  Electricity,  p.  546. 
§  Brown-Saquard's  Archives,  June,  1873. 


496  DISEASES   OF  INTEKNAL  EAE — CAUSES. 

quantity.  The  hearing  had  so  far  diminished  that  the  watch  was  not  heard 
when  pressed  upon  the  auricle,  and  the  tuning-fork  held  between  the  teeth, 
was  heard  only  in  the  left  ear.  In  the  right  ear,  however,  a  tone  of  50,000  v.  s. 
was  distinctly  heard,  and  in  the  left  ear  a  tone  of  45,000  v.  s.  The  membrana 
tympani  of  both  ears  was  transparent  and  apparently  normal,  except  that  it 
was  quite  concave.  The  hearing  wras  not  improved  by  the  use  of  either  Polit- 
zer's  air-douche,  or  the  catheter.  No  formula  of  reaction  cculd  be  obtained, 
but  the  use  of  the  cathode  increased  the  perception  for  high  musical  tones  to 
60,000  v.  s.,  and  for  duration  of  hearing  of  the  tuning-fork,  from  twenty 
seconds  to  thirty-five  seconds."  * 

"  This  increase  in  the  perception  for  musical  tones  persisted  but  a  short  time 
after  the  application  of  the  current ;  the  duration  of  perception  of  the  tuning- 
fork,  however,  continued  to  increase,  but  never  reached  the  normal  standard, 
and  the  improvement  in  the  general  hearing  was,  on  the  whole,  so  very  slight, 
that  the  use  of  the  current  was  finally  abandoned.  This  case  presented  several 
points  of  interest.  So  far  as  could  be  determined,  the  middle  ear  was  in  a 
healthy  condition,  with  exception  of  such  changes  as  were  evidenced  by  the 
concavity  of  the  membrana  tympani.  Assuming  the  auditory  nerve  to  be  in  a 
normal  state,  we  should  expect  an  increase  in  the  limit  of  perception  for  high 
musical  tones,  as  was  the  case  on  account  of  the  increased  tension  of  the  mem- 
brana tympani ;  the  same  condition  would  tend  to  diminish  the  hearing  for 
lower  tones,  as  was  the  case  in  the  test  with  the  tuning-fork,  and  in  the  hear- 
ing for  the  voice.  The  use  of  the  cathode  increased  the  hearing  for  the  voice, 
and  for  the  watch,  slightly  and  decidedly  increased  the  perception  for  high 
musical  tones,  and  also  the  duration  of  the  perception  of  the  tuuing-fork  ;  and 
an  excision  of  a  portion  of  the  membrana  tympani,  which  operation  was  sub- 
sequently performed,  had  no  appreciable  effect  upon  the  hearing  whatever.f " 

Causes. — Instead  of  attempting  to  divide  the  diseases  of 
the  labyrinth  into  numerous  forms,  I  have  thought  it  would 
better  accord  with  the  present  state  of  our  knowledge,  if  the 
causes  that  are  known  to  produce  primary  disease  of  the 
internal  ear  were  tabulated  and  discussed.  We  shall  then  at 
least  see  the  gaps  in  our  knowledge,  which  is,  after  all,  the 
best  view  for  the  scientific  student  to  take. 

I  will  venture  to  tabulate  the  causes  of  disease  of  the 
internal  ear  as  follows  : 

*  "  The  tuning-fork,  a  562  v.  s.,  being  struck  by  the  spring-hammer  with  a 
force  equivalent  to  one  pound  falling  one  inch,  the  normal  duration  of  hearing 
is  from  55  to  60  seconds." 

f  "  In  the  majority  of  cases  in  which  this  latter  operation  is  performed,  the 
perception  for  high  musical  tones  is  immediately  increased ;  in  one  case  in 
which  the  experiment  was  made,  the  patient  heard  a  tone  of  100,000  v.  s.  dis- 
tinctly, after  the  operation,  the  extreme  limit  before  the  operation  having  been 
only  a  tone  of  35,000  v.  s." 


DISEASES   OF  INTERNAL  EAR — CAUSES.  497 

Proximate  causes — 
Injuries. 

Hemorrhages  and  effusions. 
Inflammation  of  the  membranous  labyrinth. 
Internal  administration  of  quinine. 
Concussion  of  the  nerve,  and  its  expansion. 

Remote  causes — 
Syphilis. 

Cerebro-spinal  meningitis. 
Fevers. 

The  exanthemata. 
Mumps. 

Cerebral  tumors. 
Aneurism  of  the  basilar  artery. 

INJURIES. 

It  is  readily  seen  that  a  fracture  of  the  petrous  portion  of 
the  temporal  bone,  attended,  as  it  must  necessarily  be,  by 
laceration  of  the  tissues  of  the  membranous  labyrinth,  with 
unstringing  of  the  fibres  that  make  up  Corti's  organ,  must 
produce  great  impairment,  if  not  total  loss  of  the  functions  of 
the  auditory  nerve.  Such  an  injury  may  be  accompanied  by 
hemorrhage  through  the  membrana  tympani ;  but  a  case  of 
Zaufal's,  quoted  by  Politzer,*  shows  that  a  hemorrhage  may 
occur  from  the  ear  after  an  injury  when  the  drum-head  is 
intact.  In  this  case  a  fracture  occurred  through  the  upper 
wall  of  the  pyramid  and  the  opposite  wall  of  the  tympanic  cav- 
ity, and  extended  to  the  upper  wall  of  the  osseous  part  of  the 
auditory  canal,  without  having  injured  the  membrana  tympani. 

A  serous  discharge  from  the  ear,  after  a  fracture  of  the 
base  of  the  skull,  is  a  symptom  that  is  spoken  of  by  most 
surgical  authorities.  The  fluid  that  escapes  is  usually  cerebro- 
spinal fluid,  but  Politzer  t  quotes  a  case  from  Pedi,  in  which 
the  fluid  must  have  come  from  the  labyrinth,  for  there  was  no 
trace  of  a  fracture  of  the  skull  found  in  the  post-mortem  ex- 

*  Lasion  des  Labyrintlies.    Arcliiv  fur  Ohrenheilkunde,  Bd.  II. 
f  L.  c. 

32 


498  HEMOEEHAGE  INTO  LABYEINTH. 

animation,  made  three  years  after  the  injury,  although  the 
stapes  was  fractured,  and  there  was  a  free  communication 
between  the  cavity  of  the  tympanum  and  the  vestibule.  Hyrtl, 
after  removing  the  fluid  from  the  canal  of  the  spinal  cord  in 
the  cadaver  of  a  child,  once  found  that  the  injecting  material 
forced  into  it  passed  into  the  cavities  of  the  labyrinth.  He  is 
of  the  opinion  that  the  labyrinth  fluid  in  this  case,  was  con- 
nected with  that  of  the  cerebro-spinal  cavity  by  holes  which 
existed  in  the  meatus  auditorius  externus,  near  the  entering 
fibres  of  the  auditory  nerve.  It  is  therefore  conceivable,  as  Po- 
litzer  suggests,  that  the  cerebro-spinal  fluid  may,  in  some  cases, 
flow  from  the  ear,  after  an  accident,  without  a  fracture  of  the 
base  of  the  skull.  The  question  as  to  whether  the  cavity  of  the 
spinal  column  and  the  labyrinth  are  normally  in  communica- 
tion with  each  other  in  the  adult  subject  is  not  yet  settled. 
In  foetal  life  such  a  communication  exists.  It  is  unnecessary 
to  dwell  upon  the  kind  of  injuries  that  may  produce  injuries 
to  the  labyrinth.  The  text-books  on  general  surgery  are  the 
proper  sources  of  information  of  this  kind,  and  to  them  I 
may  be  permitted  to  refer  the  reader  for  a  fuller  account 
of  such  injuries. 

HEMORRHAGE  OR  EFFUSION. 

I  think  we  have  a  right  to  conclude,  from  the  clinical  his- 
tory of  certain  cases,  that  a  hemorrhage  or  effusion  of  serum 
into  the  membranous  labyrinth  may  occur  without  any  well- 
defined  cause.  Of  course,  in  atheromatous  degeneration  of 
other  blood-vessels  of  the  body,  we  may  also  suppose  that 
such  a  hemorrhage  sometimes  occurs.  The  following  case  is 
a  fair  type  of  what  is  meant  by  hemorrhage  or  effusion  into 
the  labyrinth  : 

Profound  Deafness  of  both  Ears,  accompanied  by  Vomiting,  and  loss  of  Equi- 
librium, occurring  in  one  night. 

A  healthy  young  man  of  22,  consulted  me  at  the  instance  of  Dr.  Howard 
Pinkney,  and  gave  the  following  history  :  His  occupation  was  that  of  a  wag- 
oner. He  was  attacked  one  night  with  vomiting  and  dizziness,  and  in  a  few 
hours  he  found  himself  completely  deaf  in  both  ears.  He  could  not  hear  the 
loudest  sounds.     The  nausea  and  dizziness  continued  for  about  two  weeks. 


HEMORRHAGE  LNTO  LABYRINTH.  499 

He  was  so  weakened  that  he  could  not  get  out  of  bed,  but,  lie  retained  his 
intellect  and  consciousness,  and  lie  stated  that  there  was  no  paralysis  of  any 
part  of  his  body  ;  he  could  lift  his  head,  his  arms,  move  his  legs,  and  all  parts 
of  his  body.  There  were  no  cases  of  cerebro-spinal  meningitis  in  the  place 
where  this  attack  occurred.  He  had  had  a  suppuration  in  the  right  ear  some 
years  before,  and  could  not  hear  well  from  that  ear  before  this  attack.  It  is 
now  three  months  since  his  deafness  came  on,  and  he  is  no  better.  The  patient 
is  ruddy,  and  in  vigorous  health  ;  there  is  no  cardiac  or  renal  disease.  He  has 
not  had  syphilis.  He  walks  with  a  staggering  gait.  His  intellect  is  un- 
clouded. He  has  tinnitus  aurium,  which  he  compares  to  the  chirping  of 
crickets.  The  vision  is  good.  He  is  still  dizzy  at  times.  An  objective  exam- 
ination showed  evidences  of  old  inflammation  in  the  right  membrana  tympani ; 
but  there  was  no  inflammatory  action  going  on.  The  membrane  was  trans- 
parent, except  on  the  posterior  and  inferior  quadrant,  where  it  was  sunken 
and  adherent  to  the  wall  of  the  tympanic  cavity.  The  left  membrana  tympani 
was  normal.  He  did  not  hear  the  watch  at  all,  nor  words  spoken  through 
a  tube  placed  in  the  external  meatus.  Air  enters  botli  Eustachian  tubes. 
The  tuning-fork  was  not  heard  better  when  the  ears  were  stopped. 

I  think  there  is  no  reasonable  doubt  that  this  was  a  case 
of  hemorrhage  into  the  semicircular  canals  and  the  cochlea.  I 
have  seen  several  such,  and  some  where  no  vomiting  occurred, 
but  sudden  deafness  with  absolutely  no  premonition.  We  are 
still  in  need,  however,  of  post-mortem  investigations  to  estab- 
lish our  theories  founded  on  clinical  experience.  Inasmuch  as 
such  patients  do  not  usually  die  of  the  labyrinth  disease,  we 
have  not  the  same  facilities  for  clearing  up  a  diagnosis  that 
we  have  in  fatal  affections. 

The  following  case  was  furnished  me  by  Dr.  R.  S.  Tracy, 
who  observed  it  while  house  physician  in  Bellevue  Hospital. 
It  seems  to  be  one  of  inflammatory  effusion  into  the  labyrinth, 
and  to  fairly  belong  to  this  group  of  cases,  although  both 
Dr.  Tracy  and  myself  agree  that  the  evidence  is  not  quite 
positive. 

Syphilitic  Periostitis  of  Internal  Auditory  Canal,  or  of  the  Periosteum  of  the 

Labyrinth. 

Patrick  Freely,  set.  40,  native  of  Ireland,  laborer.  Admitted  to  Bellevue 
Hospital,  March  27, 1868. 

The  patient  was  first  seen  in  the  evening,  at  about  six  o'clock.  He  was 
then  seated  on  a  stool  beside  his  bed,  with  his  head  between  his  hands,  and 
elbows  on  his  knees,  rocking  himself  from  side  to  side,  with  frequent  groans, 
as  if  in  considerable  pain.  On  my  approach  he  looked  up,  and,  when  spoken 
to,  replied  that  he  was  unable  to  hear  a  word,  that  he  had  acute  pain  in  his 
head,  shooting  through  from  ear  to  ear,  and  that  he  felt  giddy,  so  that  he  stag- 


500  PERIOSTITIS   OF  LABYRINTH. 

gered  in  walking  like  a  drunken  man.  Tins  was  all  the  history  that  could  be 
obtained  from  him,  as  he  could  not  hear  the  loudest  shouts  uttered  close  to  bis 
ear,  and  he  was  found  to  be  unable  to  read  or  write.  All  doubt  as  to  his  actual 
deafness  was  dispelled  by  his  manner  of  speaking.  His  voice  was  very  loud, 
and  badly  modulated.  He  was  given  one-half  grain  of  morphine,  to  relieve 
his  pain,  and  left  till  morning. 

The  next  day  he  had  less  pain,  and  remarked  that  it  was  always  worse  at 
night.  He  was  found  to  have  enlarged  post-cervical  ganglia,  and  a  copper- 
colored,  non-inflammatory  papular  eruption  over  the  whole  body.  A  cicatrix 
was  also  found  upon  the  glans  penis. 

From  the  evidence  of  syphilis  present,  the  nocturnal  exacerbations  of  the 
pain  in  his  head,  the  fact  that  his  deafness  was  of  recent  occurrence  (a  fact 
learned  from  his  friends),  its  symmetrical  character,  and  the  absence  of  other 
cerebral  symptoms  than  deafness  and  a  certain  degree  of  giddiness,  the  diag- 
nosis was  made  of  syphilitic  periostitis  of  the  internal  auditory  canal,  and  he 
was  given  iodide  of  potassium,  in  ten-grain  doses,  three  times  a  day. 

He  continued  in  much  the  same  condition,  excepting  that  his  pain  was 
somewhat  alleviated,  until  the  morning  of  April  1st,  when  he  was  found  to 
have  marked  facial  paralysis  on  the  left  side.  The  face  was  considerably  dis- 
torted whenever  he  talked  or  laughed. 

April  5th. — Eruption  fading  rapidly.  Facial  paralysis  also  improving.  No 
lesion  of  sensation  or  motion  in  any  other  part  of  the  body. 

April  6th. — Facial  paralysis  almost  gone.  On  the  evening  of  this  day, 
when  spoken  to  in  a  loud  voice,  he  heard  what  was  said  to  him — the  first  indi- 
cation of  a  returning  sense  of  hearing. 

April  10th. — Pain  in  the  head  entirely  gone.  Hearing  somewhat  further 
improved.    Eruption  stationary. 

April  11th. — Patient  hears  now  when  addressed  in  a  tone  but  little  louder 
than  ordinary  conversation.  But  it  has  been  noticed  for  several  days,  since  he 
began  to  regain  his  hearing,  that  after  conversing  for  a  short  time  his  hearing 
becomes  blunted,  perhaps  from  local  congestion. 

April  13th. — Hearing  still  further  improved.  Still  complains  of  dizziness, 
and  his  gait  is  unsteady.     Eruption  disappearing. 

April  lAth. — Facial  paralysis  gone.  Hears  when  conversed  with  in  an 
ordinary  tone. 

April  21st. — Continued  improvement.  Still  staggers  in  walking,  and  com- 
plains of  noises  in  his  ears.     Eruption  gone. 

May  11th. — Patient  continued  to  improve  steadily,  his  gait  becoming  more 
natural,  and  his  dizziness  less  and  less,  until  to-day,  when  he  was  discharged 
at  his  own  request,  not  perfectly  relieved,  but  in  pretty  good  condition. 

This  case  is,  I  think,  another  hint  at  the  truth  of  Volto- 
lini's  idea  of  a  true  inflammation  of  the  membranous  laby- 
rinth, although  it  is  not  a  pure  case  of  this  disease.  It  was, 
perhaps,  one  of  effusion  about  the  trunk  of  the  auditory  and 
facial  nerves. 


INFLAMMATION   OF  MEMBRANOUS   LABYRINTH.  501 


INFLAMMATION  OP    MEMBRANOUS   LABYRINTH. 

Inflammation  of  the  membranous  labyrinth,  suppurative  or 
exudative  in  character,  is,  as  I  have  already  said,  a  disease, 
which  I  unite  with  the  author  just  alluded  to,  in  believing  may 
exist,  and  that  it  may  be  and  is  mistaken  for  cerebro- spinal 
meningitis.  I  would  ask  those  who  see  a  great  deal  of  dis- 
eases of  children,  to  accurately  note  the  symptoms  of  doubtful 
cases  of  cerebro-spinal  meningitis,  and  see  if  we  may  not  have 
a  primary  inflammation  of  the  labyrinth,  as  well  as  one  of  the 
membranes  of  the  brain  and  the  medulla  oblongata.  The 
symptoms  of  epidemic  cerebro-spinal  meningitis,  as  given  by 
Clymer,*  are,  "  great  prostration  of  the  vital  powers,  severe 
pain  in  the  head  and  along  the  spinal  column,  delirium,  tetanic 
and  occasionally  clonic  spasm,  and  cutaneous  hyperesthesia, 
with,  in  some  cases,  stupor,  coma,  and  motor  paralysis,  at- 
tended frequently  with  cutaneous  hemic  spots."  Dr.  Clymer's 
definition  is  so  comprehensive  and  guarded  that  it  would  be 
difficult  to  say,  that  the  symptoms  of  labyrinth  disease  as 
given  by  Yoltolini,  may  not  accord  with  those  of  cerebro-spinal 
meningitis.  I  am  inclined  to  think  that  Dr.  Clymer  has  made 
his  definition  very  comprehensive,  in  order  to  take  in  the 
sporadic  cases.  Yoltolini  regards  these  as  affections  of  the 
labyrinth.  Yoltolini  says,f  "  The  children  are  attacked  quite 
suddenly,  and  without  apparent  cause  ;  consciousness  is  soon 
lost  as  a  rule,  but  the  head  is  frequently  grasped  with  the  hands. 
There  is  severe  fever,  a  fixed  countenance.  They  bury  the 
head  in  the  pillow.  There  are  sometimes  slight  symptoms  of 
paralysis,  but  they  are  never  permanent ;  occasionally  there  is 
vomiting.  Sometimes  the  disease  has  something  of  an  inter- 
mittent character.  The  cerebral  symptoms  soon  disappear, 
but  the  patient  is  found  to  be  perfectly  deaf,  and  walks  with  a 
staggering  gait." 

Yoltolini  lays  particular  stress  upon  the  absence  of  facial 
paralysis  in  these  supposed  cases  of  cerebro-spinal  meningitis, 

*  Reprint  from  the  American  edition  of  Aitken's  Science  and  Practice  of 
Medicine,  1872. 

f  Monatsschrift  fur  Olirenheilkunde,  Jalirgang  I.,  No.  1. 


502  INFLAMMATION  OF  MEMBRANOUS  LABYRINTH. 

and  be  asks  how  is  it  possible  to  have  an  exudation  in  the 
medulla  oblongata,  at  the  origin  of  the  auditory  nerve,  with- 
out having  at  the  same  time  one  of  the  facial,  when  the  fibres 
of  the  two  nerves  are  so  near  each  other.  Dr.  H.  Knapp  can- 
not agree  with  Voltolini  in  his  idea  of  primary  inflammation 
of  the  membranous  labyrinth,  and  has  discussed  the  subject 
quite  fully  in  a  "  clinical  analysis  of  inflammatory  affections  of 
the  middle  ear."*  Knapp's  argument  against  Voltolini's  view 
is  embraced  in  the  following  question  :  "  If  the  same  complex 
symptoms  in  some  cases  produce  deafness,  in  others  blind- 
ness, and  in  many  others  neither,  why  should  we  call  the 
first  group  otitis  labyrinthica,  mistaken  for  meningitis,  while 
in  the  second  group  the  dependence  of  the  ocular  affection 
on  the  cerebro-spinal  disease  may  be  -demonstrated  ?"  Yol- 
tolini went  too  far  in  thinking  that  there  was  no  such  dis- 
ease as  cerebro-spinal  meningitis,  which  causes  deafness ; 
but  because  so-called  "  spotted  fever"  does  exist,  and  trans- 
mits disease  to  the  auditory  and  optic  nerves,  this  fact  fur- 
nishes no  evidence  that  primary  affections  of  the  nerve-trunks, 
or  of  their  expansions,  may  not  occur,  just  as  we  may  have 
primary  neuritis  optica.  But  here,  also,  gaps  in  our  knowl- 
edge are  to  be  rilled,  a  task  that  must  be  performed  by  the 
post-mortem  examinations  of  the  practitioners  of  the  present 
or  future. 

Severe  Headache  and  Vomiting — Partial  Delirium — Deafness  in  a  few  days — 
No  Paralysis— Recovery  of  all  symptoms  out  Deafness. 

Sally  A.,  set.  13,  May  3,  1873.  Three  months  ago  this  child  was  attacked 
with  vomiting  and  pains  in  the  head.  She  became  only  slightly  delirious. 
There  was  no  paralysis  of  any  kind.  The  hearing  was  found  to  be  impaired 
in  a  very  few  days,  and  she  became  deaf  soon,  and  has  remained  so.  She 
was  taken  sick  on  Saturday,  and  on  Wednesday  she  heard  as  badly  as  now. 
She  is  now  perfectly  deaf,  but  concussions  hurt  her  ears.  She  walks  with  diffi- 
culty, that  is,  the  gait  is  staggering. 

The  practitioner  will  judge  for  himself  as  to  how  much 
inflammation  of  the  spinal  cord,  or  membranes  of  the  brain, 
there  is  in  such  cases  as  the  above. 

*  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1. 


CONCUSSIONS — QUININE.  503 

CONCUSSIONS. 

Workmen  employed  in  hammering  large  iron  plates,  such 
as  are  used  in  making  the  boilers  of  steam-engines,  are  very 
apt  to  lose  much  of  their  hearing  power.  I  am  informed  by 
the  superintendents  and  workmen  of  some  such  factories,  that 
a  large  proportion  of  the  men  who  have  been  long  in  the  hor- 
rid din  of  a  boiler  shop,  become  deaf.  So  many  of  these  cases 
were  found,  that  at  one  time  "  Boiler-makers'  Deafness"  fig- 
ured as  a  separate  disease  of  the  ear  in  the  statistical  reports 
of  one  of  our  institutions  where  aural  disease  was  treated. 
Examination  of  such  cases  has  shown  me  that  the  lesion  caus- 
ing the  impairment  of  hearing  and  deafness,  must  be  sought 
for  in  the  labyrinth,  and  that  is  probably  due  to  concussion  of 
the  fibres  of  the  nerve  in  the  cochlea  and  semicircular  canals. 

Concussions  of  the  labyrinth,  from  cannonading,  such  as 
are  sometimes  experienced  by  soldiers,  and  sailors  also,  belong 
to  this  class  of  labyrinth  affections.  Deafness  from  such  con- 
cussions, without  an  affection  of  the  tympanic  cavity,  is  very 
rare  however. 

QUININE. 

There  is  no  doubt  but  that  large  doses  of  quinine  may 
cause  temporary  affections  of  the  labyrinth,  which  are  made 
known  by  tinnitus  aurium  and  impairment  of  hearing.  Yet  I 
am  inclined  to  think  that  such  a  congestion  is  not  peculiar  to 
the  membranous  labyrinth,  but  that  it  may  also  occur  in  the 
tympanic  cavity  and  in  the  auditory  canal,  from  the  adminis- 
tration of  quinine.  It  is  so  well  known  that  buzzing  in  the  ear 
is  caused  by  quinine,  that  many  persons  who  are  becoming 
gradually  deaf  from  chronic  catarrhal  or  proliferous  inflamma- 
tions of  the  middle  ear,  and  who,  as  is  the  case  with  most  other 
persons  in  our  country,  have  taken  some  quinine  in  their  time, 
jump  at  the  conclusion  that  the  quinine  caused  the  impair- 
ment of  hearing  from  which  the}7  suffer.  Exact  examination 
often  shows  that  many  of  such  patients  have  never  taken 
quinine  enough  to  cause,  or  even  to  cure  any  disease.  I 
have  grown  suspicious  of  quinine,  however,  in  aural  disease,  in 


504:  EEMOTE  CAUSES — SYPHILIS. 

any  considerable  doses ;  for  I  have  been  convinced  by  experi- 
ence that  it  has  a  peculiar  power  of  congesting  the  auditory 
apparatus.     The  case  on  page  155  is  an  evidence  of  this  fact. 

REMOTE  CAUSES— SYPHILIS. 

Among  the  remote  causes  of  disease  of  the  internal  ear, 
syphilis  is  especially  prominent.  Yet  it  should  not  be  for- 
gotten that  syphilitic  affections  of  the  middle  ear,  are  more 
common  than  those  of  the  labyrinth.  It  should  also  be 
remembered  that  the  inflammations  of  the  ear  that  may  occur 
in  the  course  of  syphilis,  have  no  pathognomonic  symptoms. 
There  are  no  marks  by  which  we  can  distinguish  them  from 
other  affections  of  the  same  nature,  in  which  there  is  no 
syphilitic  diathesis.  It  is  only  by  other  evidences  of  the 
existence  of  the  poison  in  the  system  that  we  can  be  assured 
of  the  syphilitic  nature  of  a  given  case  of  aural  disease. 
Where,  for  example,  in  the  course  of  constitutional  syphilis, 
we  have  paralysis  of  the  facial  of  the  seventh  pair  of  nerves 
and  at  the  same  time  the  hearing  begins  to  be  impaired, 
we  have  good  reason  to  suspect — if  the  pharynx  and  Eusta- 
chian tubes  do  not  show  positive  evidences  of  disease — that 
we  have  also  an  affection  of  the  portio  mollis  of  this  pair. 
The  tuning-fork  will  then  aid  us  in  making  a  differential  diag- 
nosis. It  is  probable,  however,  that  the  middle  ear  is  usually 
also  affected  in  the  cases  of  impairment  of  hearing  that  occur 
in  the  course  of  syphilitic  disease.  The  pathology  of  syphi- 
litic aural  disease  is  not  exactly  known  ;  but  we  have  good 
reason  for  believing  that  we  may  have  periostitis  of  the  laby- 
rinth as  well  as  gummata.  Besides,  we  may  have  a  lesion  of 
the  meatus  auditorius  internus,  and  of  the  nerve-trunk  itself. 

Mr.  Hutchinson*  is  of  the  opinion  that  all  of  the  cases 
which  he  inspected,  of  aural  disease  occurring  in  the  course  of 
inherited  syphilis,  are  "  due  either  to  disease  of  the  nerve  itself 
or  to  some  change  in  non-accessible  parts  of  the  auditory 
apparatus."  I  fear  that  Mr.  Hutchinson  has  not  attached 
enough  importance  to  the  throat  symptoms  in  his  cases,  and 

*  A  Clinical  Memoir  on  certain  Diseases  of  the  Eye  and  Ear,  consequent 
on  Inherited  Syphilis.     London,  1863. 


NERVOUS  DEAFNESS  FROM  SYPHILIS.  505 

that  thus  he  has  been  led  to  give  diseases  of  the  laby- 
rinth an  undue  preponderance  in  aural  affections  resulting 
from  syphilis.  The  fact  that  the  Eustachian  tubes  are  pervi- 
ous, goes  but  a  very  little  way  to  sustain  the  theory  of  laby- 
rinth disease,  and  Mr.  Hutchinson  admits  that  his  cases 
showed  changes  in  the  membrana  tympani,  but  not  "  ade- 
quate" ones.  The  following  case  illustrates  the  difficulty 
of  making  a  positive  differential  diagnosis  between  middle 
ear  and  labyrinth  disease  in  the  existence  of  a  syphilitic 
diathesis : 

Acute  Pain  in  right  side  of  Head  along  the  course  of  the  Seventh  Nerve,  fol- 
lowed by  impairment  of  Hearing  and  Tinnitus  Aurium — Gradual  loss 
of  Hearing  more  marked  on  the,  right  side — Primary  Sypldlis  one  year 
since,  followed  by  Mucous  Patches  and  Erythema. 

Mr.  X.,  set.  29,  May  26,  1873,  was  sent  to  me  for  advice,  by  Dr.  R.  Hubbard, 
of  Bridgeport,  Conn.  The  following  history  was  given  by  Dr.  Hubbard  and 
the  patient :  One  year  ago  he  had  a  chancre  in  the  urethra,  followed  by  mu- 
cous patches  and  erythema.  He  was  treated  by  the  use  of  mercury  and  iodide 
of  potassium,  and  recovered  very  rapidly  from  those  symptoms.  About  five 
weeks  ago  the  patient  was  seized  with  a  severe  pain  in  the  track  of  the  facial 
nerve,  with  tinnitus  aurium.  The  tinnitus  was  compared  by  the  patient  to 
the  peep  of  a  chicken,  although  this  variety  of  noise  was  not  the  only  one 
observed.  There  was  no  pain  in  the  ear  itself.  The  general  health  is  excel- 
lent. The  hearing  had  gradually  diminished  in  the  right  ear  since  the  pain 
and  tinnitus  occurred.  The  pain  subsided  in  a  short  time  ;  the  tinnitus  still 
continues.  The  hearing  distance  is — R.,  Eijs|!i? ;  L.,  £f.  The  tuning-fork  is 
heard  more  distinctly  in  the  better  ear.  When  the  right  ear  is  closed  by  the 
finger,  however,  the  tuning-fork  is  heard  better  in  that  ear.  The  membranse 
tympani  of  both  sides  are  sunken,  that  of  the  left  more  so.  The  light  spot  is 
nearly  obliterated  on  the  right  side.  There  is  a  small  one  on  the  left.  Infla- 
tion of  the  ears  by  Politzer's  method  improves  the  hearing  a  very  little  on 
each  side.     The  pharynx  is  secreting  excessively. 

I  suppose  this  to  be  a  case  of  sub-acute  catarrh  of  the 
middle  ear,  with  a  secondary  affection  of  the  labyrinth.  The 
affection  of  the  facial  may  have  occurred  during  its  passage 
through  the  tympanic  cavity,  or  possibly  at  its  cerebral  origin. 
The  tuning-fork  indicates  that  there  is  labyrinth  disease,  and 
yet  the  test  is  not  positive,  because  when  the  right  ear  was 
closed,  the  sound  of  the  fork  was  intensified  on  the  side  of  the 
closed  ear.  The  appearances  of  the  drum-head,  and  of  the 
pharynx,  as  well  as  the  results  from  the  employment  of  Polit- 


506  CEREBROSPINAL  MENINGITIS. 

zer's  method,  are,  however,  positive  proofs  that  some  catarrh 
of  the  middle  ear  exists.  The  patient  is  under  treatment  both 
constitutional  and  local. 

Mr.  Hutchinson  speaks  only  of  hereditary  syphilis  in  his 
book,  but  there  is  the  same  tendency  to  catarrh  of  the  pha- 
rynx and  Eustachian  tubes  in  inherited  syphilis  as  in  any 
other  form. 

The  prognosis  in  disease  of  the  labyrinth,  occurring  in  the 
course  of  syphilis,  is  very  unfavorable.  I  have  never  seen  a 
case  of  recovery. 

MENINGITIS— CEREBRO-SPINAL  MENINGITIS. 

Meningitis  and  cerebro-spinal  meningitis  lead  to  disease 
of  the  labyrinth  by  direct  transition  of  the  inflammatory  ac- 
tion. Disease  of  the  middle  ear  also  results  from  those  affec- 
tions, and  I  have  seen  many  cases  where  the  two  parts  of  the 
ear  were  simultaneously  affected.  The  deafness  is  not  usu- 
ally observed  until  the  patient  is  aroused  from  the  stupor, 
when,  if  the  labyrinth  be  affected,  the  deafness  is  profound, 
and  there  is  apt  to  be  unsteadiness  of  the  gait.  Knapp* 
speaks  of  some  cases,  however,  where  the  deafness  occurred 
during  convalescence.  This  is  a  state  of  things  that  we  some- 
times see  in  labyrinth  disease  from  scarlet  fever,  where,  after 
a  slight  catarrhal  inflammation  of  the  middle  ear  the  laby- 
rinth becomes  suddenly  invaded,  probably  from  the  middle 
ear,  and  secondary,  incurable  disease  of  the  internal  ear 
occurs.  Fortunately,  in  scarlet  fever  and  in  the  other  exan- 
themata, middle  ear  and  not  labyrinth  disease,  is  the  variety 
of  aural  affection  usually  found.  In  cerebro-spinal  meningitis, 
however,  the  labyrinth  is  the  part  of  the  ear  that  usually  is 
attacked ;  at  least,  even  if  the  middle  ear  be  diseased,  the 
labyrinth  is  also.  The  nature  of  the  lesion  in  deafness  from 
cerebro-spinal  meningitis,  is  not  yet  fully  made  out.  Suppu- 
ration of  the  membranous  labyrinth  has  been  found  in  some  of 
the  very  few  post-mortem  examinations  that  have  been  made.f 
It  is  probable  that  the  seat  of  the  lesion  is  to  be  found  in  the 

*  Medical  Becord,  vol.  vii.,  No.  15,  p.  340. 

j-  Knapp,  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1,  p.  47. 


CEREBRO-SPINAL  MENINGITIS — ANEURISM.  507 

labyrinth  proper,  and  not  in  the  auditory  nerve-trunk,  for  the 
facial  nerve  is  seldom  affected. 

Yon  Troltsch*  says  that  a  few  post-mortem  examinations 
show  that  the  morbid  changes  causing  deafness  in  cerebro- 
spinal meningitis,  are  sometimes  found  in  the  fourth  ventricle. 
It  is  as  yet  an  assumption  to  say  that  suppuration  of  the  laby- 
rinth is  the  usual  lesion. 


ANEURISM— TUMORS. 

Aneurism  of  the  basilar  artery,  cerebral  tumors,  and,  in 
fact,  all  varieties  of  intracranial  disease,  may  cause  tinnitus 
aurium  and  impairment  of  hearing  ;  but  all  such  cases  require 
special  study,  and  hardly  demand  a  detailed  notice.  Griesen- 
ger  says  that  the  symptoms  of  disease  of  the  nerve,  or  its 
expansion,  arising  from  aneurism,  are :  Difficulty  in  swallow- 
ing ;  occasionally  spasmodic  deglutition  ;  impairment  of  hear- 
ing, or  even  complete  deafness,  often  appearing  at  intervals, 
with  great  tinnitus  ;  difficulty  of  respiration  and  articulation ; 
interference  with  the  excretion  of  urine ;  without  any  impair- 
ment of  the  intellectual  functions;  and,  finally,  paraplegia. 
"Van  Troltsch  states  that  a  constant  sensation  of  knocking,  in 
the  back  of  the  head,  is  also  a  suspicious  symptom. 

Dr.  Hughlings  Jackson  believes  that  deafness  (excluding 
cases  manifestly  due  to  disease  of  the  apparatus  of  hearing)  is 
a  rare  complication  of  intracranial  disease.  It  is  very  much 
less  common  than  optic  neuritis.  Dr.  Jackson  has  not  yet 
seen  an  autopsy  which  showed  that  deafness  had  depended 
upon  adventitious  products,  nor  upon  "  any  sort  of  disease  of 
either  cerebral  hemisphere."  One  casef  is  recorded,  however, 
which  Dr.  Jackson  quotes,  of  tumor  of  the  left  cerebral  hemi- 
sphere, where  there  has  been  deafness  of  both  ears.  Dr.  Jack- 
son thinks  that  deafness  does  not  result  from  intercranial 
tumor,  or  other  adventitious  product,  unless  the  auditory 
nerve  is  actually  involved  or  pressed  upon. 

Pathology. — In  passing  over  the  subject  of  the  causes  of 

*  Von  Troltsch,  second  American  edition,  p.  511. 

f  Royal  London  Ophthalmic  Hospital  Reports,  vol.  iv.,  part  iv.,  p.  420. 


508 


PATHOLOGY  OF  NERVOUS  DEAFNESS. 


disease  of  the  internal  ear,  we  have  alluded  to  the  pathology  of 
the  affection  ;  but  it  may  be  well  to  tabulate  the  post-mortem 

appearances  that  have  been  found  in  the  labyrinth.  Inasmuch 
as  very  few  of  these  appearances  have  been  accompanied  by 
the  history  of  the  case,  they  have  not  the  importance  that  they 
would  otherwise  have  had.  Yet  they  may  be  of  service  as  a 
basis  for  future  investigation  : 

Absence  of  auditory  nerve, 1 

Atrophy  of  auditory  nerve, 10 

Suppuration, 1 

Tumor  upon, 1 

Hemorrhage  upon, 2 

Thickened  membranous  labyrinth, 11 

Atrophy  of  membranous  labyrintb, 22 

Congestion, 1 

Suppuration  of  membranous  labyrinth,       ....  2 

Serum  in  labyrinth, 3 

Opaque  fluid  in  labyrinth, 3 

Black  pigment  cells  too  abundant 1 

Distension  of  blood-vessels  of  cochlea,         ....  3 

Black  pigment  very  abundant 4 

Fluid,  opaque,      .........  4 

Pus  in  cochlea, 1 

Thickened  lamina  spiralis, 1 

Osseous  wall  of  semicircular  canals  incomplete,         .        .  3 

Pus  in  canals, 1 

Calcareous  matter  in  canals, 1 

Hemorrhage  into  canals, 1* 

Hyperemia  of  cochlea  and  semicircular  canals,f 

Ecchymoses  in  vestibule  and  cochlea,  seen  by  Politzer| 
accompanied  by  ecchymoses  of  the  tympanic  cavity  and 
osseous  tube, 

Hemorrhage  into  the  whole  labyrinth,  after  the  action  of 
the  poisons  of  gout,  typhus  fever,  scarlatina,  measles,  or' 
mumps,  observed  by  Toynbee,§ 


*  The  above  cases  are  taken  from  the  tabulated  index  of  Toynbee's  cata- 
logue. Many  of  them  are  secondary  changes,  but  they  show  what  may  occur 
in  the  labyrinth. 

f  Voltolini,  Virchow's  Archiv,  Bd.  XVII. ;  Schwartze,  Archiv  fur  Ohren- 
heilkunde,  Bd.  I.,  p.  206.  Schwartze's  case  was  one  of  acute  catarrh  of  the 
tympanic  cavity  after  typhoid  fever. 

%  Moos,  Klinik  der  Ohrenkrankheiten,  p.  311. 

§  Diseases  of  the  Ear,  American  reprint,  p.  377. 


NEEVOUS  DEAFNESS — TEEATMENT.  509 

Fibro-muscular  tumor  in  the  infundibulum  of  the  cochlea 
was  found  by  Voltolini,* 

Phosphate  of  lime  on  lining  of  the  meatus  auditorius  in- 
ternus,  Boettcher,-|- 

Atrophy  of  membranous  labyrinth, 16 

Soft  and  swollen, •  .  10 

Fatty 2 

Endolymph  opaque  or  red, 17 

Labyrinth  containing  pus,  ....... 

Labyrinth  containing  cholestearine, 

Bony  degeneration  of  saccule, 

Thickened  lamina  spiralis,  .        .        .        .        . 

Fibrous  mass  in  cochlea, 

Excess  of  pigment, 3 

Extravasation  of  blood, 2 

Bony  deposit  in  meatus  auditorius  internus,      ...  2 

Atrophy  of  fibres  of  auditory  nerve, 3| 

It  must  be  observed  that  suppuration  in  the  membranous 
labyrinth  is,  as  yet,  among  the  rarest  of  pathological  changes 
that  has  been  found  in  the  internal  ear,  although  it  is  assumed 
by  some  authorities  that  this  is  the  lesion  that  usually  results 
from  cerebro-spinal  meningitis. 

Treatment. — Only  general  remarks  can  be  made  in  reference 
to  the  treatment  of  disease  of  the  labyrinth.  Each  case  must 
be  studied  by  itself,  and  treated  according  to  the  symptoms. 
If  we  have  to  deal  with  a  case  of  true  inflammation  of  the 
labyrinth,  cold  applications  to  the  head  and  the  use  of  quinine 
should  be  avoided,  and  our  reliance  must  be  on  leeches  and 
counter-irritation,  pedeluvia  and  purgatives.  Chronic  affec- 
tions of  the  labyrinth  are,  so  far  as  my  experience  goes, 
utterly  hopeless.  The  effusions  in  the  labyrinths  due  to  syphi- 
lis are  less  amenable  to  treatment  than  any  other  form  of  sec- 
ondary venereal  disease.  Electricity  has  a  much-vaunted  repu- 
tation among  inexact  observers,  for  its  cures  of  nerve-deafness  ; 
but  there  are  no  authentic  cases  on  record  of  a  cure  of  a  true 
inflammatory  affection  of  the  labyrinth  by  this  agent.  The 
only  seeming  exception  to  this  rule  is  a  case  reported  by 

*  Moos,  1.  c,  p.  316. 

f  Von  Troltsch,  translation,  p.  499. 

X  Hinton,  Nervous  Deafness,  reprint  from  Guy's  Hospital  Reports,  1867. 


510  NERVOUS  DEAFNESS — TREATMENT. 

Moos,*  which  he  entitles  "Recovery  of  Complete  Nervous 
Deafness."  The  constant  current  was  used  successfully  in 
what  seems  to  me  to  have  been  a  case  of  impairment  of 
hearing  occurring  in  the  course  of  an  hysterical  affection.  The 
patient  had  acute  articular  rheumatism,  and  in  the  fifth  week 
hysterical  symptoms  appeared.  There  was  great  sensitive- 
ness of  the  ear,  such  as  occurs  in  other  parts  of  the  body  in 
hysterical  women,  and  increased  hearing  power.  The  patient 
lay  for  nine  days  without  moving  on  the  right  side,  and  thus 
an  ulcer  of  the  concha  was  caused.  She  took  large  closes 
of  quinine  for  these  nine  days,  when  impairment  of  hearing 
occurred,  and  continued  to  increase  until  the  patient  was 
communicated  with  in  writing.  In  the  eleventh  week  tetanic 
spasms  occurred.  The  galvanic  current  was  then  employed, 
twelve  elements  being  used.  The  symptoms,  except  the  deaf- 
ness, soon  subsided,  and  a  thorough  course  of  galvanization 
of  the  ear  restored  the  power  of  the  right  one  perfectly,  and 
of  the  left  in  all  respects,  except  the  inability  to  distinguish 
the  highest  note  of  the  seven-octave  piano. 

I  confess  I  do  not  feel  the  enthusiasm  over  this  case  which 
is  exhibited  by  Professor  Moos,  which,  according  to  his  hopes, 
is  to  "  toll  the  knell  for  all  the  opponents  of  the  therapeutic 
value  of  electricity  in  aural  disease."  It  has,  to  say  the  least, 
so  strong  an  hysterical  element,  as  to  make  it  doubtful  what 
pathological  process  was  at  the  basis  of  the  deafness,  and 
yet  it  is  an  interesting  and  important  case.' 

Beard  and  Rock  well  t  give  their  views  as  to  the  value  of 
electricity  in  the  treatment  of  diseases  of  the  auditory  nerve 
and  labyrinth  in  the  following  cautious  language  :  "  Cases  of 
nervous  deafness,  or  of  deafness  resulting  from  various  patho- 
logical conditions,  with  which  a  morbid  condition  of  the  audi- 
tory nerve  is  complicated,  and  all  cases  of  tinnitus  aurium, 
whatever  may  be  their  supposed  pathology,  should  only  be 
regarded  as  hopeless  after  the  failure  of  persevering  and  va- 
ried treatment  by  electricity,  although  perfect  or  approximate 
cures  will  be  obtained  only  in  a  small  percentage  of  the  cases. 
The  treatment  of  opacity  and  thickening  of  the  drum,  and  of 

*  Archives  of  Ophthalmology  and  Otology,  Bd.  I.,  No.  2. 

f  A  Practical  Treatise  on  Medical  and  Surgical  Electricity,  pp.  571-2. 


NERVOUS  DEAFNESS — TREATMENT.  511 

chronic  inflammation  (with  the  consequent  adhesions  and  other 
morbid  changes)  of  the  middle  ear  and  Eustachian  tube,  offers 
a  fair  and  important  field  for  electrical  experiment." 

Dr.  Knapp  sajs  :*  "  I  have  tried  it  (electricity)  in  nearly  all 
reported  cases,  but  without  a  shade  of  improvement." 

Dr.  S.  Sexton,  of  this  city,  Surgeon  to  the  New  York  Ear 
I)ispensary,  writes  me  that  he  has  experimented  with  electri- 
city in  aural  disease  for  two  years,  both  in  private  and  public 
practice.  He  is  convinced  of  the  correctness  of  Brenner's  for- 
mula ;  but  in  all  his  cases,  Dr.  Sexton  says  "  there  was  no 
marked  improvement  in  the  hearing."  "  In  a  few  cases  of 
impaired  hearing,  where  there  were  the  accompanying  symp- 
toms of  dizziness  or  nervous  headache,  the  advantages  of  the 
treatment  were  decided." 

My  own  experience  has  been  purely  negative.  I  have 
never  seen  any  improvement,  in  any  forms  of  nerve  deafness, 
from  the  use  of  electricity  in  any  form.  I  fear  that  we  must 
abandon  the  hopes  entertained  by  some,  of  the  powers  of  this 
subtle  agent  in  those  as  yet  mysterious  diseases,  the  affections 
of  the  internal  ear. 

OTALGIA. 

The  subject  of  otalgia  belongs,  strictly  speaking,  to  the 
middle  ear ;  but  I  have  followed  the  custom  of  other  text- 
books, and  insert  a  brief  notice  of  this  affection  at  this  point. 

True  otalgia  may  occur  as  a  consequence  of  malarial  poi- 
soning, of  syphilis,  or  of  carious  teeth.  The  chief  point  in  the 
differential  diagnosis  is  the  absence  of  swelling  or  redness  of 
the  visible  parts  of  the  ear,  and  the  non-impairment  of  the 
hearing.  I  do  not  remember  to  have  seen  but  two  cases.  One 
of  these  seemed  to  have  been  the  result  of  malaria ;  the  other, 
of  syphilis.f  Dr.  R  F.  Weir,  of  this  city,  has  seen  two  cases, 
the  result  of  decayed  teeth.     The  ear,  especially  the  tympanic 

*  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1. 

■f  The  author  would  be  very  glad  of  opportunities  to  examine  the  labyrinth 
in  fatal  cases  of  cerebro-spinal  meningitis.  The  petrous  bones  may  be  placed 
in  Midler's  fluid.  R.  Bichromate  of  potash,  2£  grammes ;  sulphate  of  soda, 
1  gramme  ;  distilled  water,  100  grammes.     M. 


512  OTALGIA. 

cavity,  is  so  richly  supplied  with  nerves,  that  it  is  surprising 
that  so  few  cases  of  otalgia  have  been  observed.  Bonnafont* 
says  that  the  disease  rarely  attacks  both  ears  at  once,  but  that 
it  readily  passes  from  one  to  the  other,  in  consequence  of  the 
sympathy  between  the  two  sides  of  the  fifth  pair.  There  is 
apt,  according  to  the  same  author,  to  be  injection  of  the  con- 
junctiva and  lachrymation,  in  connection  with  otalgia. 

The  seat  of  otalgia  may  be,  according  to  Bonnafont,  in  the 
auditory  nerve,  the  chorda  tympani,  or  the  nerve  supply  of  the 
tympanic  cavity.  Bonnafont  advises  instillation  into  the  ear 
of  a  concentrated  decoction  of  poppy-heads  and  cataplasms, 
or  blisters  on  the  auricle  and  mastoid  process. 

Gruberf  reports  a  case  of  typical  otalgia  cured  by  the  use 
of  iodide  of  potassium.  Quinine  was  tried,  but  proved  of  no 
service. 

Gruber  thinks  it  possible  that  there  was  an  exudation 
pressing  upon  the  nerve  in  this  case.  The  symptoms  were 
spasmodic  contraction  of  the  left  side  of  the  head,  with  pain 
in  the  ear  occurring  at  irregular  intervals  ;  the  longest  inter- 
missions were  a  few  days.  The  hearing  power  was  normal, 
and  there  were  no  pathological  objective  symptoms. 

The  following  case,  which  I  have  as  yet  seen  but  once,  is  a 
fair  representation  of  pure  otalgia  : 

Otalgia  of  Right  Bide,  probably  from  Syphilitic  Exudation  on  the  Seventh  Nerve. 

A.  X.,  set.  27.  May  23,  1873. — This  patient,  who  is  a  physician,  says  that 
he  has  suffered  from  more  or  less  acute  pain  in  the  right  ear  and  the  mastoid 
process  for  three  months.  Within  the  last  ten  days  it  has  been  more  severe. 
The  hearing  is  not  impaired.  On  examination  the  hearing  distance  is  found 
to  be  normal,  but  the  tuning-fork  is  heard  better  on  the  right  side.  The  mem- 
brana  tympani  and  mastoid  process  are  in  a  normal  condition.  The  pain 
seems  to  follow  the  course  of  the  seventh  nerve.  The  patient  has  had  pri- 
mary syphilis,  and  also  some  secondary  symptoms.  He  has  never  had  any 
malarial  disease. 

I  supposed  this  to  be  a  case  of  otalgia  from  exudation 
upon  the  seventh  nerve  in  its  course  through  the  tympanic  cav- 
ity, and  advised  the  employment  of  anti-syphilitic  treatment. 

*  Traite  theoretique  et  pratique  des  Maladies  de  l'Oreille.     Paris,  1873. 
f  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  9. 


PART  IV. 
DEAF-MUTEISM  AND  HEARING  TRUMPETS. 


CHAPTER    XX. 

DEAF-MUTEISM— HEARING  TRUMPETS. 

Deaf-muteism  is  caused  by  diseases  of  the  middle  and 
internal  ears.  These  diseases  are  of  various  kinds,  and  have 
been  fully  discussed  in  the  preceding  chapters  of  this  work. 
The  only  reason  that  deaf  persons  become  mutes  is  that  the 
disease  of  the  ear  occurs  either  before  birth,  or  so  shortly 
after,  that  its  victim  is  unable  to  learn  to  imitate  speech. 
There  are  no  changes  in  the  larynx  that  prevent  deaf-mutes 
from  articulating  distinctly,  except  those  that  may  possibly 
come  from  disuse  of  the  organ. 

Persons  who  become  completely  deaf  later  in  life,  do  not 
lose  the  power  of  speech  ;  but  they  usually  speak  in  an  unna- 
tural tone,  because  they  are  unable  to  hear  their  own  voice 
with  distinctness. 

Deaf-mutes  may  be  divided  into  two  great  classes. 

I. — The  acquired  cases,  or  those  in  whom  the  disease  of  the 
ear  has  occurred  after  birth,  from  some  traceable  cause. 

II. — The  congenital  cases. 

It  is  very  difficult  to  come  to  a  correct  conclusion  as  to  the 
relative  frequency  of  congenital  and  acquired  deaf-muteism. 
The  tables  that  are  made  up  by  the  directors  of  schools  for 
the  deaf  and  dumb  are  not  trustworthy,  because  they  are  taken 
from  the  statements  of  persons  who  are  seldom  exact  observ- 
ers— the  parents  or  friends  of  the  children.  Dr.  George  M. 
Beard  and  myself*  examined  two  hundred  and  ninety-six 
cases  of  deaf-muteism,  with  their  histories,  in  the  schools 
of  New  York  City,  and  Hartford,  Conn.,  and  the  result  of  our 
examination  was,  that  about  sixty-one  per  cent,  of  these  cases 

*  American  Journal  of  the  Medical  Sciences,  vol.  liii.,  p.  401. 


516  DEAF-MUTEISM. 

were  probably  congenital,  and  that  the  remaining  thirty-nine 
per  cent,  were  acquired.  Wilde's  statistics  show  that  about 
fifty  per  cent,  are  of  the  acquired  form.  The  exact  truth  as 
to  the  time  when  the  deafness  occurred,  is  something  very 
difficult  to  ascertain.  It  is  not  easy  to  learn,  even  when  great 
pains  are  taken  by  persons  well  competent  to  observe,  whether 
a  very  young  infant  hears  well  or  not,  although  we  may  easily 
satisfy  ourselves  whether  or  not  loud  sounds  are  perceived. 
Wilde*  says  that  children  appear  to  be  conscious  of  sounds 
during  the  third  month,  while  at  the  fourth  they  show  an 
appreciation  of  particular  sounds,  such  as  chirping,  whistling 
and  the  like.  He  believes  that  from  the  fourth  to  the  sixth 
month  is  perhaps  the  earliest  period  at  which  an  opinion 
can  be  formed  as  to  the  hearing  of  an  infant.  Moreover, 
an  inflammation  of  the  ear,  if  not  of  the  suppurative  variety, 
may  run  its  entire  course  in  a  young  child,  and  never  be 
recognized  by  physician  or  friends  as  a  case  of  aural  dis- 
ease. It  is  "well  known,  and  the  fact  has  been  before  alluded 
to  in  this  volume,  that  a  suppurative  inflammation  of  the  mid- 
dle ear,  in  an  infant,  is  sometimes  first  recognized  as  such 
when  the  pus  breaks  through  the  membrana  tympani.  The 
fact  that  such  severe  processes  may  go  on  in  the  ears  of  chil- 
dren, and  escape  recognition,  renders  it  very  probable  that 
even  Wilde's  proportion,  in  which  he  gives  fifty  per  cent,  as 
the  proper  one  for  acquired  deaf-muteism,  is  too  low  a  one. 
I  am  inclined  to  think  that  many  more  children  become  deaf 
after  birth  than  those  who  are  born  so. 

It  does  not  require  absolute  deafness  in  a  young  child  to 
produce  deaf-muteism.  A  case  of  chronic  aural  catarrh,  that 
would  only  inconvenience  a  grown  person,  will  make  an  infant 
so  stupid  that  it  will  soon  cease  to  attempt  to  imitate  speech. 
We  have  all  grades  of  hearing  power  in  so-called  deaf-mutes. 
I  have  seen  two  or  three  cases  of  children  who  were  being 
educated  in  deaf  and  dumb  asylums,  who  could  hear  words 
spoken  into  their  ears  in  a  very  loud  tone.  In  one  case  the 
parents  found  it  too  much  trouble,  inasmuch  as  no  physician 
could  be  found  who  would  treat  the  suppurating  ear,  to  teach 

*  Aural  Surgery,  English  edition,  p.  461. 


DEAF-MUTEISM — CAUSES.  517 

their  child  to  speak.  He  was  consequently  losing  his  speech, 
and  also  having  his  life  placed  in  peril  by  the  neglect  of  the 
ulcers  in  his  ears. 

Causes. — The  causes  of  deaf-muteism  are  very  graphically 
set  down  in  the  reports  of  deaf  and  dumb  asylums,  but  unfor- 
tunately these  assigned  causes  are  usually  incorrect.  Thus, 
"  colic,"  "  a  burn,"  "  a  fall,"  "  fits,"  "  mother  marked,"*  etc., 
figure  in  such  tables  as  causes  of  deaf-muteism.  Many  of  the 
so-called  facts  in  such  tables  have  been  derived  from  unscien- 
tific observers,  who  sometimes  have  very  positive  opinions  as 
to  the  causes  of  disease,  and  who  believe  that  in  a  severe 
fright  to  the  mother,  the  marriage  of  cousins,  etc.,  ample 
causes  are  found  for  deaf-muteism.  The  investigation  of  the 
proximate  causes  of  deaf-muteism,  show,  as  has  been  said, 
that  their  victims  have  become  deaf  from  precisely  the  same 
kinds  of  disease,  and  in  about  the  same  proportion  as  obtains 
in  impairment  of  heariDg  or  deafness  occurring  at  a  time  of 
life  that  prevents  the  subjects  from  becoming  dumb  as  well  as 
deaf.  Of  the  296  cases  examined  by  Dr.  Beard  and  myself, 
in  only  22  cases  was  the  drum-head  found  to  be  normal,  and 
in  200,  or  more  than  two-thirds  of  the  whole  number  exam- 
ined, there  was  chronic  pharyngitis  or  tonsilitis.  It  is  thus 
seen  that  the  middle  ear  was  usually  the  seat  of  the  lesion 
that  caused  the  deafness.  Of  the  114  acquired  cases,  the 
membrana  tympani  was  perforated  in  twenty-nine  cases. 
Thus,  suppurative  inflammation  does  not  seem  to  cause  as 
large  a  proportion  of  deaf-muteism  as  is  usually  supposed. 
In  some  of  the  cases,  however,  the  membrani  tympani  had  once 
been  perforated  and  had  healed.  In  Blake's  statistics,t  forty 
per  cent,  of  those  examined,  forty-one  in  number,  were  classed 
by  him  as  acquired  cases.  In  twelve  of  these  acquired  cases 
the  membrana  tympani  was  perforated  or  destroyed  on  one 
or  both  sides.  In  thirteen  of  the  seventeen  cases,  the  deaf- 
ness was  traceable  to  the  pharyngitis  of  scarlet  fever  or 
measles. 

*  On  the  Etiology  of  Acquired  Deaf-Muteism,  by  Clarence  J.  Blake.    Reprint 
from  Boston  Medical  and  Surgical  Journal. 

•J-  Reprint  from  Boston  Medical  and  Surgical  Journal. 


518  DEAF-MUTEISM. 

The  remote  causes,  or  the  causes  that  tend  to  produce 
disease  of  the  ears  in  intra-uterine  or  infantile  life,  form  a 
very  interesting  study,  but  we  have  as  yet  no  very  accurate 
data  upon  which  to  discuss  them.  It  is  an  open  question, 
perhaps,  whether  intermarriage  tends  to  produce  disease  of 
the  ear  in  young  subjects  or  not,  or  whether  it  tends  to  lead 
to  arrested  development  in  young  children  ;  for  there  is  no 
doubt  that  some  cases  of  congenital  deafness  depend  upon 
want  of  proper  development  of  the  auditory  nerve  and  laby- 
rinth. I  was  informed  at  Hartford,  that  a  certain  part  of  our 
country,  which  is  somewhat  isolated  from  the  other  parts  of 
the  Union,  and  where  intermarriages  are  the  rule,  furnished 
a  proportionately  large  contingent  of  cases  of  congenital  deaf- 
muteism.  The  cases  from  this  district  that  I  saw,  were  in 
persons  somewhat  deficient  in  intellect,  and  we  may  consider 
their  etiology  as  identical  with  that  of  idiocy,  feeble  brains,  or 
partial  development  of  other  parts  of  the  body,  such  for 
example,  as  spina  bifidis,  coloboma  iridis,  etc. 

Voltolini's  inflammation  of  the  membranous  labyrinth  is 
probably  one  of  the  proximate  causes  of  acquired  deaf-mute- 
ism.  Von  Troltsch  showed  that  a  purulent  process  is  -a  very 
common  appearance  in  the  tympanic  cavities  of  half-starved 
foundlings.  I  suppose  that  the  mal-nutrition  of  parents  may 
be  traced  as  remote  causes  for  such  affections  of  the  mid- 
dle ear.  We  may  sum  up  the  causes  of  deaf-muteism,  as 
developed  in  clinical  histories  and  in  examinations  on  the 
dead  subject,  as  follows  : 

1.  Inflammation  of  the  middle  ear,  resulting  in  suppura- 
tion, or  adhesions,  anchylosis  of  the  ossicula  auditus,  etc. 

2.  Inflammation  of  the  nerve  or  labyrinth,  resulting  in 
suppuration  or  thickening  of  the  membranous  labyrinth, 
deposits  in  it,  etc. 

3.  Arrested  development  of  some  parts  of  the  essential 
part  of  the  auditory  apparatus,  for  example,  absence  of  the 
semicircular  canals,  or  of  the  cochlea. 

These  are  the  causes  which  are  shown  in  the  table  given 
by  Moos,*  in  his  account  collected  from  various  authorities,  of 

*  Klinik  der  Ohrenkrankheiten,  p.  341. 


DEAF-MUTEISM.  519 

sections  of  the  ears  of  sixty  deaf-mutes,  and  they  agree  well 
with  the  clinical  examinations  and  histories. 

Treatment. — There  is  certainly  no  peculiar  treatment  neces- 
sary for  the  deafness  of  young  children,  which  renders  them 
mute,  because  they  cannot  learn  to  imitate  speech ;  but  I  can- 
not refrain  from  alluding  to  the  lingering  remains  of  the  bar- 
barism of  the  past  centuries,  which  neglects  the  care  of  the 
ulcerated  membrana  tympani,  and  the  swollen  throats  of  the 
poor  mutes  who  suffer  from  chronic  suppuration  and  catarrh 
of  the  middle  ear.  Although  the  educational  wants  of  deaf- 
mutes  are  now  well  attended  to,  their  medical  treatment  is 
sadly  neglected  in  the  asylums  and  schools  of  our  country.  It 
was  not  until  the  seventh  century  that  deaf-mutes  were  thought 
worthy  of  an  education.  The  twentieth  century  will  probably 
arrive  before  every  school  or  asylum  for  these  unfortunates  has 
in  attendance  a  physician  who  knows  how  to  examine  and  treat 
a  diseased  ear.  These  schools  are  not  hospitals,  it  is  true ; 
but  there  is  always  in  them  quite  a  large  proportion  of  young 
patients,  who  still  suffer  from  a  disease  which,  although  it 
has  fully  destroyed  the  hearing,  is  not  yet  stayed,  and  which 
often  goes  on  to  destroy  life.  I  refer,  of  course,  more  particu- 
larly to  the  suppurative  forms  of  disease. 

According  to  the  census  of  1870,  there  were  in  the  United 
States,  sixteen  thousand  two  hundred  and  five  deaf-mutes  :  of 
these  we  may  believe  that  fifty  per  cent,  belong  to  the  acquired 
cases.  How  many  of  these  belong  to  what  may  fairly  be 
called  preventable  diseases,  it  would  not  be  possible  to  say ; 
but  certain  it  is,  that  if  diseases  of  the  ear  had  always  rejoiced 
in  the  same  attentive  treatment  as  many  of  the  less  essential 
parts  of  the  body  have  received,  the  number  of  these  unfortu- 
nate mutes  would  have  been  greatly  lessened. 

HEARING  TRUMPETS. 

We  have  not,  as  yet,  been  furnished  with  an  apparatus  for 
conducting  the  undulations  of  sound  to  the  ear,  which  is  at  the 
same  time  efficient  and  unconspicuous.     This  is  the  great  de-  < 
sideratum  of  most  patients  who  are  affected  with  incurable 


520 


HEAEING  TEUMPETS. 


impairment  of  hearing,  for  nearly  all  deaf  persons  would  like 
to  conceal  their  infirmity.  It  is  possible  that  the  development 
of  the  science  of  acoustics  will  yet  furnish  us  with  a  sound  lens, 
that  will  refract  and  focus  rays  of  sound  upon  the  drum-head 
and  assist  the  hearing  power  ;  but  in  the  very  nature  of  things 
it  is  not  likely  that  we  shall  ever  have  an  apparatus  so  well 
adapted  to  the  pathological  changes  in  a  diseased  ear,  as  are 
convex  lenses  to  the  physiological  process  of  thickening  of  the 
crystalline  lens  and  rigidity  of  the  ciliary  muscle,  which  we  term 
presbyopia.  The  physician  can  only  therefore  advise  his 
patients  to  use  one  of  the  simple  conductors  of  sound  that  are 
here  delineated,  as  being  all  that  science,  as  yet,  offers  to  the 
hopelessly  deaf. 

Fig.  110. 


Hearing  Trumpets. 


It  will  be  seen  that  the  first  is  a  flexible  speaking  tube, 
which  is  very  convenient  for  conversation,  and  is  in  fact  called 
a  conversation  tube.  The  second  and  third  figures  represent 
the  ordinary  metallic  trumpets  which  aid  many  persons  with 
impaired  hearing  to  hear  addresses,  sermons,  and  so  forth. 
In  many  churches  long  flexible  tubes  run  from  beneath  the 
pulpit  to  the  seats  of  those  whose  hearing  is  impaired,  and  are 
used  as  is  the  conversation  tube.  I  am  very  much  in  doubt 
as  to  the  value  of  the  so-called  auricles,  represented  in  the 
fourth  figure.     The  most  different  accounts  are  given  as  to 


HEARING  TRUMPETS.  521 

their  value  as  assistance  to  the  hearing  power.     They  are,  of 
course,  worn  over  the  head  and  fit  into  the  meatus. 

The  simpler  apparatus  are  usually  the  best.  It  is  some- 
times of  advantage  to  use  little  clamps  which  hold  up  the 
auricle,  as  deaf  people  do  with  their  hands,  in  order  to  catch 
all  the  waves  of  sound.  The  small  "  invisible  "  tubes,  placed 
in  the  auditory  canal,  are  wholly  useless.  There  is,  in  fact,  no 
apparatus  as  yet  invented  that  is  better  than  the  various 
forms  of  curved  tubes. 


DESCRIPTION  OF  THE  CHROMO-HTHOGRAPHS. 


Fig.  1. — Normal  membrana  tympani. 

It  is  impossible  to  exactly  render  the  normal  tint  of  tbis  beautiful  struc- 
ture, but  tbis  litbograpb  seems  to  me  to  approximate  tbis  to  a  very  satisfactory 
degree. 

Fig.  2.* — In  tbis  case,  tbat  of  a  man  tbirty-two  years  of  age,  a  purulent 
inflammation  of  tbe  middle  ear  bad  existed  for  nearly  two  years.  Tbere  was 
a  perforation  in  front  of  tbe  malleus,  wbicb  finally  bealed  under  tbe  applica- 
tion of  nitrate  of  silver,  forming  the  cicatrix  sbown  in  tbe  drawing,  and  also  a 
small  circular  opening  through  the  "  pars  flaccida  "—the  space  within  tbe  open- 
ing, and  around  tbe  malleus-incus  articulation  being  filled  with  small  granu- 
lations. After  the  closure  of  the  lower  perforation,  these  were  treated  by 
application  of  saturated  solution  of  arg.  nit.,  on  a  cotton-tipped  probe,  with 
good  result.  The  outer  layer  of  the  membrana  tympani,  above  and  behind 
the  processus  brevis,  was  much  thickened  and  congested,  and  this  condition 
(as  shown  in  the  drawing)  continued  after  the  closure  -of  the  inferior  perfora- 
tion. This  plate  is  of  value,  as  exhibiting  a  comparatively  rare  form  and 
position  of  perforation  of  tbe  membrana  tympani,  and  one  not  readily  amen- 
able to  treatment. 

Fig.  3  represents  a  small  perforation,  the  consequence  of  purulent  otitis 
media,  occurring  in  a  boy  twelve  years  of  age,  and  of  one  year's  duration. 
There  were  no  granulations  at  the  time  when  the  drawing  was  made,  and  tbe 
perforation  was  in  process  of  healing,  as  is  sbown  by  tbe  congested  blood-ves- 
sels extending  from  tbe  periphery  towards  the  perforation.  Tbis  drawing 
exhibits  the  want  of  clearness  of  the  outline  of  the  malleus,  as  the  result  of 
thickening  of  tbe  outer  layer  of  the  membrana  tympani,  and  also  tbe  promi- 
nence of  tbe  processus  brevis  and  of  tbe  posterior  fold,  in  consequence  of  the 
concavity  of  the  membrana  tympani.  Through  tbe  perforation  is  seen  tbe 
congested  mucous  membrane  of  tbe  middle  ear. 

*  The  cases  here  described  were  treated  by  Drs.  C.  J.  Blake  and  H.  L.  Shaw,  of  Boston. 


524:  DESCRIPTION  OF  THE   CHROMO-LITHOGRAPHS. 

Fig.  4. — A  case  of  purulent  otitis  media,  in  a  boy  twelve  years  of  age. 
This  drawing  represents  faithfully  the  granulations  occurring  on  the  mem- 
brana  tympaui,  and  also  the  thickening  of  the  membrana  tympani,  subsequent 
to  the  perforation,  and  during  the  continuance  of  the  purulent  inflammation. 
This  case  was  convalescent  at  the  time  the  drawing  was  made,  under  the 
application  of  astringents  to  the  middle  ear,  and  the  granulations  were  rapidly 
diminishing  under  the  application  of  arg.  nit.  Id  this  drawing,  also,  is  shown 
the  peculiar  arrangement  of  the  blood  vessels  passing  from  the  superior  wall 
of  the  meatus  into  the  membrana  tympani,  to  assist  in  forming  the  manubrial 
plexus,  and  which  are  congested  in  consequence  of  the  diseased  condition  of 
the  tympanum  and  membrana  tympani. 

Fig.  5  represents  a  case  of  chronic  catarrhal  inflammation  of  the  middle 
ear,  accompanied  by  great  concavity  of  the  membrana  tympani.  The  proces- 
sus brevis  is  very  prominent,  and  both  anterior  and  posterior  folds  of  the 
membrana  tympani  are  consequently  elongated.  The  handle  of  the  malleus 
is  much  foreshortened,  and  the  lower  end  nearly  in  contact  with  the  promon- 
torium,  as  is  shown  by  the  lighter  color  of  the  membrana  tympani  at  this 
point,  the  light  rays  being  reflected  directly  from  the  white  surface  of  the  pro- 
montorium.  The  concavity  of  the  membrana  tympani  is  further  evidenced  by 
the  character  of  the  light  reflection,  which,  instead  of  being  a  perfect  cone,  as 
represented  in  Fig.  1,  is  represented  by  two  small  points  of  light,  one  close  to 
the  end  of  the  malleus,  and  one  at  the  periphery ;  the  intermediate  space  repre- 
senting a  surface  of  such  degree  of  concavity  that  the  light  thrown  upon  it 
from  the  mirror  is  focussed  at  a  point  within  the  meatus. 

Fig.  6  is  a  type  of  cases  of  chronic  catarrhal  inflammation  of  the  middle 
ear,  of  long  standing,  in  which  the  mucous  coat  of  tbe  membrana  tympani 
has  become  uniformly  thickened,  with  but  a  slight  degree  of  concavity  of  the 
membrana  tympani ;  the  latter  condition  in  this  case  is  principally  evidenced 
by  the  prominence  of  the  manubrium  and  processus  brevis,  and  of  the  poste- 
rior fold.  The  same  dull  gray  color  is  found,  as  a  result  of  thickening  of  the 
mucous  coat  of  the  membrana  tympani,  following  acute  inflammation  of  the 
middle  ear. 

This  drawing  exhibits  also  the  appearance  characteristic  of,  and  the  form 
peculiar  to,  large  calcareous  deposits.  The  light  reflex  is  wanting,  in  conse- 
quence of  the  presence  of  the  calcareous  deposit  at  the  point  at  which  this 
appearance  is  found  in  the  normal  membrana  tympani. 

Fig.  7  represents  a  condition  common  to  chronic  catarrhal  inflammation  of 


DESCRIPTION  OF  THE  CHROMO-LITHOGRAPHS.  525 

the  middle  ear.  In  this  case  the  malleus  is  in  contact  with  the  promontorium, 
and  the  continuance  of  the  atmospheric  pressure  from  without  has  carried  the 
membrana  tympani  inwards,  rendering  the  malleus  exceedingly  prominent. 
The  light  color  of  the  central  portion  of  the  membrana  tympani  is  due  to  the 
reflection  of  light  from  the  inner  wall  of  the  tympanum,  and  not  to  thickening 
of  the  mucous  coat.  This  condition  is  found  where  the  trouble  has  been  con- 
fined principally  to  the  mucous  membrane  of  the  Eustachian  tube  and  anterior 
portion  of  the  tympanum,  without  the  thickening  of  the  inner  coat  of  the 
membrana  tympani,  which  is  shown  in  Figs.  5  and  6. 

Fig.  8  exhibits  the  result  of  purulent  inflammation  of  the  middle  ear  of 
long  standing,  in  a  boy  ten  years  of  age.  At  the  time  of  the  drawing  the  dis- 
charge had  ceased,  under  treatment  with  dry  cotton  packing  applied  daily, 
and  the  mucous  membrane  was  returning  to  a  normal  condition.  There  were 
two  large  perforations,  divided  by  a  narrow  bridge  of  thickened  membrana 
tympani.  The  short  process  of  the  malleus  was  very  prominent,  and  the 
manubrium  in  contact  with  the  promontory.  The  remainder  of  the  membrana 
tympani  was  much  thickened.  The  slight  congestion  about  the  short  process, 
and  along  the  manubrium,  was  due  to  the  pressure  of  the  cotton  plug,  as 
there  was  no  evidence  of  a  process  of  repair  about  the  edges  of  the  perforation. 


DISEASES   OF  THE  FAR. 

D.R.ST.J9HN  ROOSA  . 


INDEX    OF    AUTHORS. 


Achilini,  20. 

Agnew,  C.  K.,  162,  402,  403,  404,  405, 

418,  425,  430,  431,  437,  438. 
Albini,  B.  G.,  59. 
Alcmseon,  19. 
Allen,  Peter,  310. 
Ambrose,  D.  R.,  418,  431. 
Arneman,  J.,  66,  419,  421,  422,  425. 
Apollonius,  30. 
Arnold,  P.,  26,  202,  219. 
Aristotle,  19. 
Arcbigines,  29. 
Arcularius,  Jobannes,  32. 
Ausspitz,  116. 
Autenreitb,  379. 
Asclepiades,  29. 


Banza,  Marcus,  35,  379. 

Barker,  Fordyce,  407. 

Beard,  George  M.,  313,  377,  495,  510, 

517. 
Beck,  Karl  Josepb,  38,  41, 105,  345. 
Benedetti,  Alexander,  32. 
Berger,  39,  421,  424. 
Berengario,  20. 
Bernard,  Claude,  230. 
Berres,  23. 

Billroth,  Theodor,  106,  389,  444. 
Bisbop,  Edward,  306. 
Blake,  Clarence  J.,  76,  87,  134,  139, 

164, 166,  344,  394,  397, 398,  399,  495, 

518. 
Bochdalek,  23, 185. 
Bonnafont,  26,  311,  328,  511. 
Bowman,  William,  300,  407,  428,  478. 
Brenner,  466,  492,  493,  495,  511. 
Brendel,  23. 
Brescbet,  26,  475. 

Buchanan,  Thomas,  25,  63, 161,  326. 
Buck,  A.  H.,  222,  388,  390,  425. 
Bull,  Charles  S.,  138,  265. 
Busson,  Julius,  321. 
Butcher,  William,  327. 
Buttles,  M.  S.,  310. 


Burnett,  C.  H.,  232,  340. 
Bottcher,  Claudius,  27. 
Boyer,  326. 
Bozzini,  89. 
Bussen,  Julian,  39. 

c. 

Camper,  24. 

Capivacci,  33. 

Cassebohm,  J.  H.,  23,  37. 

Casserius,  Julius,  21. 

Celsus,  29,  388. 

Cerlata,  Peter  de  la,  32. 

Cheselden,  Thomas,  295,  319,  320, 321. 

Chimani,  397. 

Clarke,  Edward  H.,  47, 124, 172,  397. 

Cleland,  Archibald,  38, 39, 93, 300, 373. 

Clymer,  Meredith,  501. 

Cock,  Thomas  H.,  359. 

Cohen,  92. 

Collis  (of  Dublin),  425. 

Conta,  Von,  79. 

Corti,  Marchese,  27,  478,  479,  482,  489. 

Cotugno,  Dominic,  23,  24,  37. 

Cooper,  Sir  Astley,  40,  319,  320,  321, 

322,  323,  324,  325,  326,  328,  329,344, 

371. 
Crampton,  Sir  Philip,  437. 
Curtis,  John  Henry,  41,  326. 
Cutter,  Ephraim,  301. 
Cuvier,  20. 
Czermak,  89. 

D. 

Davidson,  356,  361. 

Deiters,  27. 

Deleau,  41,326. 

Deleau  (Jeune),  176. 

De  Gravers,  321,  326. 

Dienert,  321. 

Draper,  William  H.,  136. 

Di  Rossi,  86. 

Duchenne,  59. 

Du  Verney,  35,  370. 

De  Vigo,  32. 


528 


INDEX  OF  AUTHOES. 


E. 
Eli,  321. 
Ely,  S.,  414. 

Elsberg,,  Louis,  292,  295. 
Eno,  Henry  C,  385,  390. 
Erb,  495. 

Erhard,  Julius,  42,  46,  74,  331. 
Eustachius,  Bartolommeo,  20,  21,  218. 


Fabricius  of  Acquapendente,  21,  35. 

Fabricius  Hildanus,  35,  176. 

Fallopius,  Gabriel,  20,  32,  367. 

Fielitz,  421. 

Follin,  425. 

Fisher,  Lewis,  127. 

Flint,  Austin,  Jr.,  230. 

Forest,  Peter,  33. 

Flourens,  466. 

Francis,  George  E. ,  435. 

Frank,  Martel,  43,  106,  422,  324. 

G-. 

Gadesden,  32. 

Galen,  19,  30. 

Gairal,  321. 

Gerlacb,  26. 

Geynes,  19. 

Goltz,  466. 

Gottstein.  481. 

Goethe,  219. 

Gray,  John  P.,  110. 

Garrod,  118. 

Green,  J.  Orne,  114, 115, 134, 141,  233, 
339,  435. 

Green,  John,  227,  345. 

Gross,  S.  D.,  152. 

Griesenger,  507. 

Gruening,  E.,  400,  402. 

Gruber,  Ignas,  45,  80. 

Gruber,  Jos  tf,  23,  47,  55,  63,  81,  102, 
111,  115,  184,  205,  224, 261,  282,  283, 
297,  298,  332,  335,  336,  337,  339,  344, 
393,  437,  438,  490,  443,  515. 

Gull,  Sir  William,  444. 

Guye,  311. 

Guyot  (Postmaster  of  Versailles',  38, 
39,  300. 

Gudden,  111. 

H. 

Hackley,  Charles  E.,  223,  257,  306, 

369,  439. 
Hagen,  R,  493. 
Hallier,  136. 
Haller,  24. 
Hartman,  Johan,  34. 
Hassenstein,  136. 


Hay,  Isaac,  152. 

Hecksher,  173. 

Helmholtz,  Heinrich,  188,  335,  489. 

Helmont,  J.  B.  Von,  35. 

Henle,  J.,  57,  60,  61,  189,  210,  461,463, 

464,  466,  473,  475,  476,  477, 479,  480, 

481,  482. 
Hendricksz,  327. 
Herodotus,  27. 
Hermann,  329. 
Hewitt,  Prescott,  448. 
Hinton,  James,  42,  45,  98,  282,  321, 

326,  342,  343,  368, 374,  376,  396, 425, 

486,  509. 
Himly,  Karl,  325,  326. 
Hippocrates,  17, 19,  28,  31. 
Hoffman  (of  Westphalia),  44,  84. 
Hoffman,  Friedrich,  37. 
Home,  Sir  Everard,  25,  40, 186. 
Hubbard,  Rob't,  322, 426, 428,  430,  490. 
Hun,  E.  R.,  107,  108,  110,  112,  113. 
Huschke,  25,  475,  477. 
Hutchinson,  Jonathan,  449,  504,  505. 
Hunold,  325. 
Hyrtl,  Joseph,  23,  27,  56,  59,  62,  185, 

235,  333,  466,  482,  498. 

I. 

Ingrassia,  Columbo,  20, 
Itard,  I.  M.,  9,  41,  76,  321,  326,  370, 
446. 

J. 

Jackson,  Hughlings,  449, 450, 451, 507. 
Jacoby  (of  Berlin),  424,  425,  438. 
Jaeger,  Edward,  84. 
Jasser,  420,  421,  423. 
Jones,  Handheld,  176. 
Jones,  T.  Wharton,  25,  186,  465,  466, 
468. 

K. 

Kessel,  J.,  160, 185, 190,  193,  203,  206. 

Kessel,  Adolph,  388. 

Knapp,  H.,  48, 105, 134, 141,  466,  490, 

502,  506,  511. 
Kramer,  Wilhelm,  41,  272,  281,  306, 

311,  328. 
Kolliker,  478,  479. 
Koppe,  265,  266,  424,  444. 
Kuchenmeister,  133. 

L. 

Lavater,  102. 
Lebert,  445,  446. 
Lee,  Charles  C,  362. 
Leschevin,  379. 
Lewis,  William  B.,  138. 


INDEX  OF  AUTHORS. 


529 


Lincke,  C.  P.,  18,  31,  33,  37,  379,  475. 

Liston,  315. 

Loring,  E.G.,  Jr.,  107,407,408,412,431. 

Lowenburg,  172. 

Lucae,  August,  26,  77,  339. 

Lusitanus,  34. 

M. 
Mach,  73. 

Magnus,  A.,  26,  228,  274,  345,  346. 
Maunoir,  325. " 
Marinus,  19. 
Marcellus,  31,  81. 
Mathewson,  Arthur,  46,  257,  377. 
Mayer,  Ludwig,  133, 162, 173, 218, 219. 
Meckel,  24. 
Merkel,  220. 
Meniere,  P.,  235,  491. 
Meyer  (of  Hamburg),  265. 
Micliaelis,  325. 
Millinger,  376. 
Monro,  Alexander,  24. 
Morgagni,  22,  24,  446. 
Moos,  S.,  47,  48,  191,  273,  282,  397, 
400,  402,  490,  495,  508, 509,  510-518. 
Miiller,  Johannes,  26,  393,  511. 
Murray,  Adolph,  419. 

N. 

Neuburg,  45,  80. 

Newton,  Homer,  46,  311,  425,  443. 
Noyes,  Henry  D.,  280,  311,  330. 
North,  Alfred,  405,  425. 


Pacini,  133. 

Pardee,  Charles  I.,  296,  302,  378,  407, 
425. 

Patruban,  Von,  23, 184 

Pare,  Ambrose,  34, 

Paullini,  36. 

Paulus,  iEginita,  31. 

Petit,  J.  L.,  37,  39,  419,  424. 

Peters,  George  A.,  294. 

Peugnet,  Eugene,  141. 

Petrequin,  160. 

Pinkney,  Howard,  347,  498. 

Pliny,  19,  388. 

Pilcher,  George,  43,  177. 

Politzer,  Adam,  23,  26,  46,  73,  74,  75, 
76,  98,  185,  187,  226,  261,  262,  263, 
264,  272,  273,  274,  280, 294,  300,  301, 
308,  309,  310,  311,  312,  313,  321,  330, 
338,  340,  341,  352,  356,  359, 360,  363, 

374,  376,  397,  404,  406,  426,  431, 436, 
437,  443,  497,  508. 

Pomeroy,  O.  D.,  159,  266,  278,  299,  300, 

375,  396. 


Post,  Alfred  C,  348,  410,  41 1 ,  443. 
Prout,  J.  S.,  70,  72,  309,  340,  341,  342, 

344. 
Prussak,  191. 
Pythagoras,  19. 


Quain,  315. 


Q. 


R. 


Rau,  328. 

Reid,  James,  314,315. 

Reynolds,  444,  449. 

Reiner,  48. 

Rhazes,  31. 

Riolanus,  Johannes,  319,  419. 

Riber,  325. 

Rivinus,  22, 184. 

Robertson,  Charles  A.,  393,  398. 

Rockwell,  A.  D.,  313,  495,  511. 

Rosenmuller,  278. 

Rollfink,  419. 

Riidinger,  N,  47,  174,  182,  197,  212, 

215,  216,  462,  463,  465. 
Rufus  (of  Ephesus),  19,  54. 
Ruysch,  F.,  23. 

S. 

Sabatier,  321. 

Santorini,  64. 

Saissy,  41,  326. 

Sarsonia,  Hercules,  33. 

Saunders,  J.  C,  40,  326. 

Savage,  315. 

Scarpa,  Antonio,  24,  37. 

Scheibenzuber,  165. 

Schlemm,  26. 

Schmiedekam,  324. 

Schultze,  Max,  475. 

Schwartze,  Hermann,  40,  46,  75,  76, 
133, 144,  246,  256,  265,  266,  279, 282, 
319,  320,  321,  324,  325,  326,  327, 329, 
330,  341,  374,  375,  398,  424,  425, 495, 
508. 

Seligman,  Prof.,  401,  402. 

Semeleder,  F.,  89. 

Sequard,  Brown,  112,  114,  495. 

Serapion,  31. 

Sexton,  Samuel,  356,  511. 

Shaw,  Henry  L.,  233. 

Shakespeare,  167. 

Shrapnell,  Henry  J.,  25,  184,  275. 

Sims,  J.  Marion,  173. 

Siegle,  276. 

Smith,  Andrew  H.,  225.  310,  345,  346. 

Smith,  Nathan  R.,  41,  326. 

Smith,  Gouverneur  M.,  257. 

Smith,  T.  Blanch,  415. 

Soemmering,  Thomas  George,  25. 


530 


INDEX  OF  AUTHORS. 


Stenon,  Nicolaus,  22. 
Sterling,  George  A.,  447. 
Steudener,  P.,  137,  389. 
Stevenson,  326. 
Sutton,  444.      * 
Swieten,  Van,  38. 
Swift,  Foster,  294. 

T. 

Tagliacottzi,  Caspar,  34. 

Teulon,  Giraud,  86. 

Tliudiclium,  J.  L.  W.,  292. 

Tlmrnam,  111. 

Todd,  Robert  B.,  472,  478. 

Tovnbee,  Joseph,  26,  42,  45,  111,  147, 
220,  229,  261,  272,  279,  281, 282,  283, 
289,  315,  328,  379,  380,  402,  403, 405, 
439,  445,  508. 

Tracy,  Roger  S.,  492,  499. 

Troltsch,  Anton  Von,  26, 35,  36,  42, 45, 
48, 64,  65, 102, 120, 122, 176, 187, 190, 
191, 196,  203,  215,  235,  244, 265, 266, 
272,  273,  282,  292,  299,  306,  328, 380, 
404,  419,  420,  423,  424,  436,466,482, 
507,  509,  518. 

Turck,  88. 

Turnbull,  Lawrence,  48. 

V. 

Valleroux,  Hubert,  327. 

Valsalva,  Antoine  Maria,  17,  22,  37, 

39,  100,  219,  274,  275,  279,  324,  363, 

419,  420,  424. 
Varolius,  Constant,  21. 
Velpeau,  114. 
Vesalius,  Constant,  20,  21 
Vieussens,  Raymond,  22. 
Vircbow,  Rudolph,  107, 109,  445,  446, 

508. 
Vogel,  J„  133. 
Volcher  Koiter,  21. 


Voltolini,  Rudolph,  42,  47,  89, 103, 16b 
169,  188,  282,  315,  316,  331,  332,  340, 
437,  438,  485,  487,  490,  500,  501,  502, 
508,  509,  518. 

w. 

Wakely,  T.,  151. 

Waltharn,  Jonathan,  23,  38. 

Wallis,  John,  36. 

Warner  (of  Ohio),  291. 

Weber,  C.  O.,  402. 

Weber,  E.  H.  (Leipsic),  73,  292. 

Weber,  Liel,  F.  E,  47,  297,  304,  319, 

332,  333,  334,  335,  337,  338,  339, 399, 

422. 
Weber,  Theodor  (Halle),  291,  292. 
Webster,  David,  158,  175,  274,  396, 

412,  413. 
Welcker,  H.,  401,  402. 
Weir,  Robert  F.,  63,  211, 228, 235, 312, 

425,  511. 
Wilde,  Sir  William,  18,  42,  44,  80,  89, 

123, 127,  151,  244,  259,  272, 281, 289, 

314,  321,  324,  327,  344,  359,  370,  393, 

394,  412,  421,  423,  424,  437. 
Willis,  Thomas,  35. 
Winslow,  24. 
Wreden,  Robert,  133, 140, 266, 305,  331, 

492,  493,  495. 

Y. 

Yearsley,  James,  43,  378,  379. 
Youx,  Amedee, 

z. 

Zaufal,  E.,497. 
Zinn,  23. 
Zieussen,  59. 
Zoja,  Giovanni,  207. 


INDEX    OF    SUBJECTS. 


Abductor  of  Eustachian  Tube,  352. 

Abscesses  of  Membrana  Tympani,  352. 

Abscesses  of  Cerebrum,  444. 

Actual  Cautery,!  443. 

Adhesions  in  Middle  Ear,  341. 

Air  Bubbles  in  Perforation  of  Mem- 
brana Tympani,  363. 

Air,  Atmospheric  use  of,  through  Ca- 
theter, 302. 

Albuminuria,  from  Chronic  Suppura- 
tion, 369. 

Anti-tragus,  19. 

Anchylosis  of  Stapes,  37. 

Aneurism  of  Basilar  Artery,  507. 

Angioma,  115,  388. 

Aqueeductus  Fallopii,  198. 

Artificial  Membrana  Tympani,  35,  43, 
378. 

Arabians,  their  Knowledge  of  Otology, 
31. 

Astringents,  129,  356,  375,  378. 

Aspergillus,  133. 

Aspergillus,  Cases  of,  141. 

Atropine  in  Acute  Inflammation,  127. 

Auditory  Rods,  479. 

Auditory  Cells,  481. 

Auditory  Canal,  External,  Relations 
of,  64. 

Auditory  Canal,  Blood  Vessels  of,  65. 

Auditory  Canal,  Examination  of,  80. 

Auditory  Canal,  Nerves  of,  66. 

Auditory  Canal,  Osseous,  63. 

Auditory  Canal,  Length  of,  62. 

Auditory  Canal,  Lining  of,  62. 

Auditory  Canal,  Suppuration  of,  129. 

Auditory  Canal,  Parasitic  Inflamma- 
tion of,  133. 

Auditory  Nerve,  first  traced,  24. 

Auditory  Nerve,  19. 

Auditory  Nerve,  Diagnosis  of  Disease 
of,  33. 

Auditory  Nerve,  Anatomy  of,  470. 

Aurilave,  122,  150. 

Auricle,  Anatomy  of,  53. 

Auricle,  Blood  Vessels  of,  59. 

Auricle,  Muscles  of,  56. 

Auricle,  Diseases  of,  102. 


Auricle,  Physiognomy  of,  102. 
Auwcle,  Functions  of,  103. 
Auricle,  Tumors  of,  106. 
Auricle,  Malignant  Disease  of,  114. 
Aural  Douche,  124. 
Authorities,  49,  50,  66,  220,  483. 

B. 

Blood-letting,  Local,  244. 
Bougies  for  Eustachian  Tube,  311. 
Bougies  in  Membrana  Tympani,  330. 
Bulging  of  Membrana  Tympani,  242. 
Brain,  Disease  of,  354. 
Breathing  through  the  Ear,  19. 
Bright's  Disease,  256. 

c. 

Calcareous  Formations  in  Auricle,  118. 

Calcareous  Formations  in  Membrana 
Tympani,  273. 

Canal,  External  Auditory,  60. 

Caries  of  Mastoid,  416. 

Caries  of  Temporal  Bone,  434,  439. 

Caries  of  Teeth,  511. 

Carcinoma  of  Middle  Ear,  392. 

Cases,  Record  of,  67. 

Cases  of  Foreign  Bodies,  173. 

Cases  of  Parasitic  Inflammation,  140. 

Cases  of  Inspissated  Cerumen,  154. 

Cases  of  Otitis  Media  Hemorrhagica, 
254. 

Cases  of  Sub-acute  Aural  Catarrh, 
252. 

Cases  of  Otitis  Media  Purulenta,  292. 

Cases  of  Death,  supposed  result  of 
Use  of  Eustachian  Catheter,  314. 

Cases  of  Perforation  of  Membrana 
Tympani,  323. 

Cases  of  Acute  Suppuration  of  Mid- 
dle Ear,  359. 

Cases  of  Chronic  Suppuration  of  Mid- 
dle Ear,  382. 

Cases  of  Exostoses,  404. 

Cases  of  Mastoid  Disease,  412. 

Cases  of  Caries,  440. 

Cases  of  Cerebral  Abscess,  452. 

Cases  of  Otalgia,  512. 


532 


INDEX  OF   SUBJECTS. 


Catarrh  of  Middle  Ear,  237,  262. 

Catarrh  of  Middle  Ear,  Sub-acute,  249. 

Cauterization  of  Pharynx,  290. 

Cauterization  of  Eustachian  Tube,  299. 

Cerebral  Abscess,  444-452. 

Cerebral  Tumors,  507. 

Ceruminous  Gland,  22,  63. 

Cerumen,  Composition  of,  160. 

Cerumen,  Supposed  Functions  of,  161. 

Cerumen,  Inspissated,  30,  34, 166. 

Chorda  Tympani,  21,  204. 

Chorda  Tympani,  Division  of,  342. 

Chorda  Tympani,  Injury  of,  230. 

Cholesteatoma,  393. 

Chloroform,  use  of,  166. 

Chronic  Non-suppurative  Inflamma- 
tion of  Middle  Ear,  349. 

Chronic  Suppuration  of  Middle  Ear, 
372-382. 

Church,  prevented  Anatomical  Stu- 
dies, 19. 

Circumscribed  Inflammation  of  Exter- 
nal Auditory  Canal,  130. 

Cochlea,  Anatomy  of,  466. 

Condensed  Air,  effects  of,  345. 

Condensed  Air  as  Source  of  Injury, 
223. 

Concussions,  effects  of,  503. 

Concave  Mirror,  81. 

Constitutional  Treatment,  289. 

Conversation,  Test  for  Hearing,  68. 

Cotton,  Plugging  Ears  with,  123. 

Corti's  Organ,  479,  489. 

Cleansing  Ears,  method  of,  374. 

Cleanliness  of  Ears,  123. 

Cotugnian  Fluid,  24. 

Cotton,  Styptic,  246. 

D. 

Deaf-Muteism,  36,  515. 

Dentition,  Difficult,  240. 

Delusions,  33. 

Dilator  of  Eustachian  Tube,  214. 

Diagnostic  Tube,  74,  97,  281. 

Diagnosis,  Differential,  between  Cen- 
tral and  Peripheral  Lesions,  33. 

Diffuse  Inflammation  of  External 
Auditory  Canal,  120- 

Double  Hearing,  186,  490. 

Douche,  Nasal,  243,  291. 

Douche,  Aural,  355. 

Draughts  of  Air,  123. 

Drum  of  the  Ear,  195. 

Ductus  Cochlearis,  476. 

E. 

Eustachian  Tube,  first  described,  20. 
Eustachian    Tube,    Examination    of, 
90-92. 


Eustachian  Tube,  Morbid  Changes  in, 

277. 
Eustachian  Tube  first  injected,  38. 
Eustachian  Tube,  Foreign   Bodies  in, 

73. 
Eustachian  Tube,  Anatomy  of,   208- 

218. 
Eustachian  Tube,  Muscles  of,  214. 
Eustachian  Tube,  Nebulizer  for,  307. 
Eustachian  Tube,  Treatment  of,  301. 
Eustachian    Tube,    Escape    of    Pus 

through,  354. 
Eustachian  Catheter,  93-96,  247,  279, 

313. 
Eustachius,  Poverty  of,  21. 
Ears,  Cutting  off  of,  34. 
Ear-rings,  55,  106. 
Ear-drops,  36,  285. 
Ear-muffs,  122. 
Egypt,  Specialists  in,  28. 
Electricity  in  Diagnosis,  492. 
Electricity  in  Middle  Ear  Disease,  312. 
Electricity  in  Checking   Ulcerations, 

377. 
Electricity    in    Disease   of    Auditory 

Nerve,  493. 
Emphysema  from  Catheter,  316. 
Epithelioma  of  Auricle,  114. 
Epilepsy,  450. 
Exanthemata,  47,  353. 
Examination  of  Patients,  67. 
Exhaustion  of  Air  from  Drum-head, 

347. 
Eczema  of  Auricle,  315-317. 
Exostoses,  119,  400,  402,  404. 
External  Auditory  Canal,  Anatomy  of, 

60. 
External    Auditory    Canal,     Circum- 
scribed Inflammation  of,  120,  130. 
External  Auditory  Canal,    Syphilitic 

Ulcers  of,  144. 
Eyelet,  Politzer's,  330. 
Eye  and  Ear  Infirmary,  New  York,  48. 

F. 

Facial  Paralysis,  199. 

Facial  Nerve,  19. 

Fenestra  Ovalis,  20. 

Fenestra  Eotunda,  20, 198. 

Fallibility  of  Galen,  19. 

Fibromata,  388. 

Fistula,  Mastoid,  420. 

Fluids  through  Eustachian  Catheter, 

304. 
Forceps,  Angular,  80. 
Foreign  Bodies,  29,  31, 162, 172. 
Forehead  Band,  86. 
Foramen  Rivinian,  184. 
Fossa  Navicularis,  53. 
Fossa  Triangularis,  55. 


INDEX  OF   SUBJECTS. 


ooo 


Fossa,  Sigmoidea,  205. 
Fowler's  Solution  in  Eczema,  118. 
Fracture  of  Malleus,  236. 
Fungus,  Vegetable,  135. 
Furuncles  of  Auditory  Canal,  130 

G-. 

Galvano-cautery,  332,  397. 

Gargles,  299,  356. 

Glycerine,  132,  151. 

Goats,  Breathing  through  Ears,  19. 

Graphium  Pencilloides,  136. 

Glands,  Ceruminous,  63. 

Granulations,  Polypoid,  396. 

H. 

Hairs  upon  Membrana  Tympani,  63. 

Hallucinations,  162,  178. 

Hsernatoma,  107. 

Hearing,  Tests  of,  68. 

Hearing  Power,  Register  of,  70. 

Hemiplegia,  449. 

Hemorrhage  into  Internal  Ear,  498. 

Helix,  first  named,  19. 

Helix,  Etymology  of,  53. 

Hearing  Trumpets,  519. 

Hyperostoses,  404. 

I. 

Illumination  of  Ear,  39. 
Intellect,  Confusion  of,  266. 
Insanity  from  Aural  Disease,  265. 
Insanity,  Vascular  Tumors  in,  108. 
Insects  in  the  Ear,  163. 
Instillations,  29. 
Incus,  200. 

Inflation  of  Middle  Ear,  99. 
Inhaler,  Iodine,  310. 
Injections,  29. 

Inspissated  Cerumen,  34,  146, 153. 
Internal  Ear,  Hippocrates  upon,  28. 
Internal  Ear,  Anatomy  of,  483. 
Internal  Ear,  Injuries  of,  497. 
Internal  Ear,  Hemorrhage  into,  498. 
Internal  Ear,  Pathology  of,  508. 
Internal  Ear,  Diseases  of,  485. 
Internal  Ear,  Necrosis  of,  438. 
Iodine,  Apparatus  for  Vapor  of,  308. 


Jugular  Vein,  199. 


Labyrinth,  first  described,  24. 
Labyrinth,  Anatomy  of,  461. 
Labyrinth,  Membranous,  470. 


Labyrinth,  Periosteum  of,  472. 
Labyrinth,  Diseases  of,  485. 
Lamina  Spiralis  Membranacea,  27, 470. 
Lamps  for  Rhinoscopy,  90. 
Laxator  Tympani  Minor,  21. 
Levator  Veli  Palati,  215. 
Leeches,  123,  244,  290, 131,  355. 
Living  Larvae,  31,  164. 
Light  Spot,  187,  250,  274. 
Ligaments  of  Ossicula,  201. 
Lobe,  19,  56. 

Life  Insurance,  Relations  of  Aural 
Disease  to,  387. 

M. 

Maculae  Cribrosse,  463. 

Malignant  Growths,  392. 

Malformations  of  Auricle,  104. 

Malleus,  186,  200. 

Malleus,  Fracture  of,  235. 

Mastoid  Cells,  20,  205. 

Mastoid,  Caries  of,  37,  205,  416,  425. 

Mastoid,  Diseases  of,  354,  408. 

Mastoid,  Trephination  of,  39,  420. 

Membrana  Basilaris,  478,  481. 

Membrana  Tympani  Secundaria,  198. 

Membrana  Tympani,  Erroneous  Anat- 
omy of,  25. 

Membrana  Tympani,  Artificial,  35,  43, 
378. 

Membrana  Tympani,  Perforation  of, 
39,  364,  368. 

Membrana  Tympani,  Method  of  Ex- 
amining, 84. 

Membrana  Tympani,  Evulsion  of,  233. 

Membrana  Tympani,  Bulging  of,  242. 

Membrana  Tympani,  Changes  in,  271. 

Membrana  Tympani,  Operations  upon, 
319. 

Membrana  Tympani,  Injuries  of,  222. 

Membrana  Tympani,  Resisting  power 
of,  224. 

Membrana  Tympani,  Increased  Ten- 
sion of,  78. 

Membrana  Tympani,  Anatomy  of,  1 81- 
195. 

Membrana  Tympani,  Mobility  of,  275. 

Membranous  Labyrinth,  501. 

Meningitis,  Cerebro-spinal,  506. 

Medicodegal  Examinations,  231. 

Middle  Ear.  Anatomy  of,  23. 

Middle  Ear^  Acute  Catarrh  of,  237. 

Middle  Ear,  Nomenclature  of  Diseases 
of,  237. 

Middle  Ear,  Mirror  for,  398. 

Middle  Ear,  Suppuration  of,  364,  372. 

Middle  Ear,  Chronic  Non-Suppurative 
Inflammation  of,  258. 

Middle  Ear,  Sub-acute  Catarrh  of,  249. 

Middle  Ear,  Pathology  of,  281. 


534 


INDEX  OF   SUBJECTS. 


Modiolus,  469. 
Murmur,  Venous,  267. 
Muscles  of  Auricle.  55. 
Muscles  of  Tympanic  Cavity,  203. 
Muscida  Sarcophaga,  165. 
Myringitis,  222. 
Myringectomy,  340. 
Myringodectomy,  332. 
Myxomata,  388. 

N. 

Nebulizer,  Eustachian,  307. 
Nebulizer,  Pharyngeal,  298. 
Necrosis  of  Internal  Ear,,  438. 
Necrosis  of  Temporal  Bone,  434. 
Neoplasia  Vascular,  115. 
Nervous  Deafness,  259,  485. 
Nerves  of  Auricle,  60. 
Nerves  of  Tympanic  Cavity,  204. 
Nerve,  Auditory,  483. 
Neuralgia,  Catarrh  mistaken  for,  241. 
Nitrate  of  Silver,  375. 
Noise,  better  hearing  in,  35. 
Nomenclature  of  Chronic  Non-Suppu- 
rative  Inflammation,  261. 


o. 

Otalgia,  511. 

Otology,  progress  of,  17. 

Otological  Society,  American,  47. 

Otoscope,  98. 

Otoscope,  Interference,  77. 

Otoscope,  Von  Troltsch's,  81. 

Otoscope,  Binocular,  86. 

Otoliths,  475. 

Othsematomata,  107. 

Otitis  Externa,  119. 

Otitis  Media  Hemorrhagica,  254. 

Otitis  Media  Hyperplastica,  261. 

Opium,  30. 

Ossicula  Auditus,  20,  200. 

Osteo- Sarcoma,  393. 


Paracusis  Willisiana,  35. 

Parasiticides,  140. 

Paracentesis  of  Membrana  Tympani, 

246,  320,  343. 
Parasitic  Inflammation   of    External 

Auditory  Canal,  133. 
Paralysis,  449. 

Parotid  Gland,  Inflammation  of,  64. 
Pathology  of  Internal  Ear,  508. 
Pathology  of  Middle  Ear,  281. 
Pharmaco-koniantron,  304. 
Pharynx,  Treatment  of,  290. 


Pharyngitis,  Granular,  277. 

Pharynx  in  Sub-acute  Catarrh,  250. 

Phlebitis,  199. 

Perforations  of  Membrana  Tympani, 
40,  324,  368. 

Perforations,  Hearing  Power  in  cases 
of,  371. 

Penicillium  Glaucum,  136. 

Periostitis,  Mastoid,  412 

Plastic  Surgery,  34. 

Polypi,  388,  390,  395. 

Politzer's  Method  of  Inflation,  42,  99, 
247. 

Politzer's  Method,  Allen's  Modifica- 
tion, 310. 

Politzer's  Method,  Hinton's  Modifica- 
tion, 251. 

Pocket  Posterior,  of  Membrana  Tym- 
pani, Division  of,  339. 

Posterior  Nares  Syringe,  353. 

Poultices,  use  of,  12,  125. 

Probes  in  Opening  of  Membrana  Tym- 
pani, 340. 

Probing,  danger  of,  147. 

Proliferous  Inflammation  of  Middle 
Ear,  262. 

Promontory,  198. 

Pregnancy  cause  of  Aural  Disease,  286. 

Pulsation  in  Tympanic  Cavity,  368. 

Pyjemia,  198,  292,  447. 

Q, 

Quinine,  effects  of,  155,  503. 


R. 

Results  of  Treatment,  Acute  Suppura- 
tion, 357. 

Results  of  Treatment,  Chronic  Non- 
suppurative Inflammation,  349. 

Bestiform  Bodies,  Section  of,  112. 

Rivinian  Foramen,  22. 

Rhinoscopy,  89. 

Rhinoscopy,  Changes  observed  in,  278. 


s. 

Saccule,  476. 

Salpingo-pharyngeus  Muscle,  217. 
Santorini  Incisurse,  62. 
Sarcoma  of  Auricle,  115. 
Sciatic  Nerve,  Section  of,  112. 
Scala  Tympani,  469. 
Scala  Vestibuli,  469. 
Scarlet  Fever  cause  of  Catarrh,  243. 
Semi-circular  Canals,  Anatomy  of,  464. 
Semi-circular  Canals,  Functions  of,  466. 
Semi-circular  Canals,  Disease  of,  491. 
Skeptic  in  Medicine,  19. 


INDEX  OF  SUBJECTS. 


535 


Small  Pox,  cause  of  Aural  Catarrh,  243. 
Sonofactors,  70. 
Specialists  in  Egypt,  28. 
Speculum,  first  used,  32. 
Speculum  for  Anterior  Nares,  91. 
Speculum,  Bi-valvular,  80. 
Speculum,  Mode  of  using,  82. 
Speculum,  Siegle's,  276. 
Speculum,  Pharyngeal,  89. 
Stapes,  20,  200. 
'Stapedius  Muscle,  20,  203. 
Sterility,  Ancient  Idea  of  Cause,  34. 
Steam,  use  of,  303. 
Stemphyllium,  136. 
Shrapnell's  Membrane,  184. 
Suppuration,  Acute,  of   Middle   Ear, 

350. 
Suppuration,  Chronic,  of  Middle  Ear, 

364,  370. 
Syringe,  first  employed,  34. 
Syringing,  Method  of,  128. 
Syringing,  Naso-pharyngeal,  290. 
Syringing,  Pharynx,  Gruber's  Method, 

297. 
Syringing,  Cavity  of  Tympanum,  342. 
Syphilitic  Ulcers,  144. 
Syphilis,  Deafness  from,  505. 
Styptic  Cotton,  398. 

T. 

Tensor  Tympani,  20,  203. 

Tensor  Tympani,  Division  of,  332. 

Therapeutics,  Progress,  27. 

Tests  of  Hearing,  68. 

Tinnitus  Aurium,  30, 135, 147, 240, 267. 

Tones,  Deafness  for  certain,  489. 


Trephining  Mastoid,  39. 
Tragus,  first  named,  19,  53. 
Treatment,  Results  of,  317,  347. 
Triangular  Spot  of  Light,  186. 
Trichothecium  Iioseum,  136. 
Tuning-fork,  71,  79,  148,  20!),  488. 
Tumors  of  Auricle,  106. 
Tumors,  Cerebral,  507. 
Tubulus  Hirsutus,  161. 
Tympanum,  Cavity  of,  195. 

u. 

Urine,  Ancient  Instillation  of,  36. 
Utricle,  473. 

V. 

Valsalvian  Experiment,  275. 
Venesection,  29. 
Vertigo,  147,  264. 
Vestibule,  Anatomy  of,  462. 
Vomiting,  effect  of,  231. 

w. 

Warm  Water,  Instillation  of,  28,  260. 
Water  in  the  Ear,  243. 
Watch  as  Test  of  Hearing,  68. 
Whooping  Cough,  231. 
Worms  in  the  Ear,  31. 


Zona  Denticulata,  27. 
Zona  Pectinata,  27. 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

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